ANAVEX2-73-RS-002 Prescreener

1
What is your name?* This field is required.
First Name
Last Name
2
When was your loved one with Rett syndrome born?* This field is required.Please use the format MM/DD/YYYY
3
Has your loved one been diagnosed with Rett syndrome by a doctor?* This field is required.
Yes
No
Not sure
4
If your loved one has been diagnosed with Rett syndrome, has the diagnosis been confirmed through genetic testing?* This field is required.
Yes
No, the diagnosis has not been confirmed through genetic testing.
No, my loved one has not received an official diagnosis of Rett syndrome by a doctor yet.
Not sure
5
Does your loved one with Rett syndrome have a parent or legal guardian capable of providing consent on their behalf? Would a parent or carer be able to accompany the person with Rett syndrome for the study visits?* This field is required.
Yes
No
6
Is your loved one with Rett syndrome able to take a small amount of liquid formulation (tablespoon) of investigational medicine, which can be mixed into juice or applesauce or other light food, once daily?* This field is required.
Yes
No
Not sure
7
How would you describe the level of motor impairment of the person with Rett syndrome?* This field is required.
Mild
Moderate
Severe
8
Approximately how many seizures does your loved one with Rett syndrome experience per month?* This field is required.
0 per month
1-3 per month
4 or more per month
9
Does your loved one with Rett syndrome experience breakthrough seizures despite current treatment with anti-epileptic medications?* This field is required.
Yes
No, their seizures are well-managed
No, they do not experience seizures
10
How many anti-epileptic drugs (AEDs), if any, is your loved one with Rett syndrome currently taking?* This field is required.
0
1-2
3
4 or more
11
Is your loved one with Rett syndrome currently under seizure control with medications, vagus nerve stimulation (VNS) or ketogenic diet?* This field is required.
Yes
No
12
What is the best email to contact you?* This field is required.Your privacy is important to us. This information will only be used to inform you of clinical research studies. It will never be disclosed to third parties except as required by law.
example@example.com
13
If you provide us with your phone number, we will only call if your loved one meets eligibility requirements for a Rett syndrome trial and we have difficulty reaching you via email.Your privacy is important to us. This information will only be used to inform you of clinical research studies. It will never be disclosed to third parties except as required by law.
Please enter a valid phone number.
14
What is your zip code and country of residence?* This field is required.
Street
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
User Agreement: By checking the box below, I the caregiver, understand that the personal information that I’m providing may be collected, shared, used and/or transferred by the study site and its staff for the purpose of enabling me, the caregiver, to be contacted to see if the child with Rett syndrome who is under my care is suitable to take part in this study and, if appropriate, to enroll in this study. I, the caregiver, understand there is no guarantee that I will be contacted by a study nurse as a result of submitting the potential participant’s personal information. I, the caregiver, acknowledge that I may withdraw interest in participating in the study at any time by speaking with a study site team member.* This field is required.This information is CONFIDENTIAL. Your information will not be shared with anyone.
I, the carer, verify that the name, email, and phone number provided belong to me, are correct, and that I am the legal representative of the potential participant for this study.
16
Please verify that you are human* This field is required.Last question ... we promise.
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