User Info |
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1) | Name (need not be real name) - required | |
2) | Email (optional) | |
3) | Gender | |
Female
Male
Unspecified
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4) | Age | |
NOTE: The information you complete in this survey will be reviewed by doctors at Harvard Medical School's McLean Hospital as part of their efforts to evaluate the therapeutic potential for these substances as a treatment for cluster headache. Your information is important! In order for your information to be included in a case report series that will be submitted to a peer-reviewed medical journal for publication, these doctors will need to communicate with you through email and/or telephone to answer a few more specific questions about your medical health and to have you sign a release form to obtain some of your relevant medical records. Your confidentiality will be maintained at all times and no identifying information would ever appear in the case report series when published. RP-1) Will you permit Dr. Andrew Sewell and/or Dr. John H. Halpern of McLean Hospital, Belmont, MA to contact you so that they can learn more details about your cluster headache diagnosis and treatment? |
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Yes No | ||
RP-2) If Yes, please provide either an email address (above) or phone number where it would be OK for them to contact you about the research: | ||
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General (required) |
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6) | What is the highest level of school you've completed? | |
7) | What is your employment history ? | |
8) | Please briefly describe in serious terms the primary symptoms of your vascular headaches | |
9) | Please briefly describe how you heard about this survey | |
10) | How long have you had vascular headaches? | |
11) | Do you suffer from | |
12) | Who have you been diagnosed by? | |
Myself
Doctor
Neurologist
- Other (please describe)
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Episodic CH Sufferers Only |
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13) | How often do your episodes/cycles occur (select closest) | |||||||||||||||||||||||||||||||||||||||
14) | How long does your episode/cycle typically last (select closest) | |||||||||||||||||||||||||||||||||||||||
15) | How many attacks do you experience each day during the peak of an episode/cycle? | |||||||||||||||||||||||||||||||||||||||
16) | What is the approximate length of each attack during the peak of an episode/cycle? | |||||||||||||||||||||||||||||||||||||||
16) | How many attacks do you experience each day during rest of the episode/cycle (on average)? | |||||||||||||||||||||||||||||||||||||||
17) | What is the approximate length of each attack during rest of the episode/cycle? | |||||||||||||||||||||||||||||||||||||||
18) | How far into your episode/cycle have you typically taken hallucinogenic treatment? | |||||||||||||||||||||||||||||||||||||||
19) | Have you found that hallucinogenic treatment works best if taken | |||||||||||||||||||||||||||||||||||||||
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NON EPISODIC CH SUFFERERS |
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20) | How frequently do your headaches occur | |||||||||||||||||||||||||||||||||||||||
21) | What is the approximate length of each attack? | |||||||||||||||||||||||||||||||||||||||
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All Headache Sufferers |
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22) | Have you ever used a hallucinogen as a treatment for your headaches? | |||||||||||||||||||||||||||||||||||||||
Yes
No
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If No, go to question 43 | ||||||||||||||||||||||||||||||||||||||||
If You Have Tried Hallucinogens |
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23) | Had you ever used a hallucinogen prior to trying them as headache treatment? | |||||||||||||||||||||||||||||||||||||||
Yes
No
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24) | Have you used a hallucinogen non-medically since you first tried them as headache treatment? | |||||||||||||||||||||||||||||||||||||||
Yes
No
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25) | Which hallucinogen(s) have you taken to treat your vascular headaches? | |||||||||||||||||||||||||||||||||||||||
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26) | For the most effective hallucinogen you've tried, what effect did it have on the following factors? | |||||||||||||||||||||||||||||||||||||||
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27) | What dose do you normally take to get optimum effectiveness? | |||||||||||||||||||||||||||||||||||||||
28) | What duration of improvement have you gotten from hallucinogens? | |||||||||||||||||||||||||||||||||||||||
29) | Was the improved period... | |||||||||||||||||||||||||||||||||||||||
30) | How many treatments did it take to produce an improved period? | |||||||||||||||||||||||||||||||||||||||
31) | If you have any comments about how hallucinogens improved or worsened your headaches, enter them below. | |||||||||||||||||||||||||||||||||||||||
32) | Were you taking any of the medications listed below immediately prior to or during the hallucinogenic treatment? (select all that are appropriate by holding down the Ctrl-key while clicking) | |||||||||||||||||||||||||||||||||||||||
Other : | ||||||||||||||||||||||||||||||||||||||||
33) | Did you follow Flash & Pinky's dosing guidelines (taking the treatment once every 5 days until an improved period was achieved, and trying each hallucinogen 3 times before switching to another if it hasn't worked)? | |||||||||||||||||||||||||||||||||||||||
34) | How would you compare the most effective hallucinogen you tried with the most effective other medication you've tried? | |||||||||||||||||||||||||||||||||||||||
35) | Has the hallucinogen of your choice ever stopped working? | |||||||||||||||||||||||||||||||||||||||
Yes
No
No Answer
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Used succesfully for years and months Used number of times during that period Used unsuccesfully for years and months Used number of times during that period |
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36) | Are you willing to accept "tripping" as a side-effect of reducing your headaches. | |||||||||||||||||||||||||||||||||||||||
37) | Have you ever had a bad trip or difficult psychological experience while on a hallucinogen? | |||||||||||||||||||||||||||||||||||||||
38) | Have you ever had a positive or mystical experience while on a hallucinogen? | |||||||||||||||||||||||||||||||||||||||
39) | How would you compare the side effects to those of other headache medications you've used? | |||||||||||||||||||||||||||||||||||||||
40) | How do you normally feel the day after taking hallucinogens? | |||||||||||||||||||||||||||||||||||||||
41) | If they were legal, would you recommend the use of hallucinogens to treat vascular headaches? | |||||||||||||||||||||||||||||||||||||||
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Mushrooms |
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42) | What type(s) have you used? [multiple cntrl-click] | |||||||||||||||||||||||||||||||||||||||
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Only For Those Who Have Not Tried Hallucinogen Treatment | ||||||||||||||||||||||||||||||||||||||||
43) | Which of the following medications have you tried to treat your headaches? (select all that are appropriate by holding down the Ctrl-key while clicking) | |||||||||||||||||||||||||||||||||||||||
Other : | ||||||||||||||||||||||||||||||||||||||||
44) | How would you describe the side effects for the medications you've tried? | |||||||||||||||||||||||||||||||||||||||
45) | If they were legal or recommended by your doctor, would you consider the use of hallucinogens to treat vascular headaches? | |||||||||||||||||||||||||||||||||||||||
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All Respondents | ||||||||||||||||||||||||||||||||||||||||
42) | Please provide any other relevant comments in the box provided: | |||||||||||||||||||||||||||||||||||||||