survey
INFORMED CONSENT ............................................................................................................ PLEASE ONLY PARTICIPATE IF YOU SUFFER FROM MIGRAINES ............................................................................................................. I am asking for your voluntary participation in a Social Science Research project. Please read the following information about the project below. If you would like to participate, please sign below. Purpose of the Project: Examine migraines and diets. If you participate you will be asked to: take a survey asking about your migraines and dietary habits. Time required for participation: 2-7 minutes Risks: We see no risk or stress beyond your normal day. If by chance completing this survey should cause you stress beyond your normal day please see Marla Kilfoyle at 678-7532 or at mkilfoyle@oceansideschools.org, and/or your guidance counselor. Benefits: The results of the study will allow people suffering with migraines to become aware of how diet can influence a migraine sufferer. How confidentiality will be maintained: Your name will not go on anything that is used for data.Participation in this study is completely voluntary. If you decide not to participate there will not be any negative consequences. Please be aware that if you decide to participate, YOU MAY STOP AT ANY TIME and you may decide not to answer any specific questions.By signing this form I am attesting that I have read and understand the information above. I have had any questions answered regarding this project and the above. I freely give my consent to participate. *
How old are you? *
Your answer
What gender do you identify with? *
What is your race do you identify with? *
How often do you get a migraine? *
How severe are your migraines? *
*
I Eat Often
I Eat Sometimes
I Never Eat
Meats
Fish
Chicken
Eggs
Bacon
Hot Dogs
Ham
Pepperoni
Salami
Liverwurst
Milk
Yogurt
Parmesan
Blue Cheese
Mozzerella
Pancakes
Cereal
Pasta
Sourdough Bread
Carrots
Tomatoes
Pumkins
Raw Onion
Pickles
Olives
Teriyaki Sauce
Apples
Cherries
Oranges
Pineapples
Bananas
Nuts
Homeade Soup
Canned Soup
Decaf Coffee
Soda
Tea
Alcoholic Beverages
Candy
Cake
Cookies
Jelly
Choclate
Mincemeat Pie
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