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Low Mood Questionnaire
Please fill out all required questions - this will help us determine your eligibility for the study. The questionnaire will take approx. 4 mins to complete.
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1
Full Name
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This field is required.
First Name
Last Name
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2
What is your sex?
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Female
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Other
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3
Date of Birth
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-
Date
Month
Day
Year
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4
Today's Date
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Date
Month
Day
Year
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5
Hidden - Days Calculation
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6
Hidden - Age Calculation
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7
Hidden - Age Form Value
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8
Hidden - Age Pass/Fail
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9
Please enter your weight and height
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This field is required.
Note: You can toggle between imperial and metric using the arrow icon
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10
Hidden - BMI Calculation
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11
Hidden - BMI Form Value
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12
Hidden - BMI Pass/Fail
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13
Do you have any current psychiatric diagnosis by a physician or healthcare professional?
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e.g. depression, anxiety, ADHD, schizophrenia, bi-polar
Yes
No
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14
Hidden - Do you have any current psychiatric diagnosis by a physician or healthcare professional?
e.g. depression, anxiety, ADHD, schizophrenia, bi-polar
Yes
No
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15
Please specify what condition and when you were diagnosed
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16
Have you been diagnosed with any (other) medical condition?
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e.g. High blood pressure, high cholesterol, celiac disease, etc
Yes
No
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17
Hidden - Have you been diagnosed with any medical conditions
*
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e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
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18
Please specify what medical conditions or psychiatric diagnosis you have
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19
Have you recently started any cognitive behavioural therapy or psychotherapy in the last 3 months?
*
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Yes
No
I've been in therapy for more than 3 months
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20
Hidden - Have you undergone any cognitive behavioural therapy or psychotherapy in the last 3 months?
*
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Yes
No
I've been in therapy for more than 3 months
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21
Are you currently taking any medications or supplements?
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i.e. any medication or supplement e.g. daily blood pressure meds, diabetes, cholesterol, multivitamin, etc
Yes
No
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22
Hidden - Are you currently taking any medications or supplements?
*
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Yes
No
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23
Please specify what medications or supplements you are currently taking
*
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If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure
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24
Over the last 2 weeks, how often have you been bothered by any of the following problems?
*
This field is required.
Not at all
Several days
More than half the days
Nearly everyday
Little interested or pleasure in doing things
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling down, depressed or hopeless
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Trouble falling asleep, staying asleep, or sleeping too much
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Feeling tired or having little energy
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Poor appetite or overeating
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Feeling bad about yourself – or that you’re a failure of have let yourself or your family down
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Trouble concentrating on things, such as reading the newspaper or watching television
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Moving or speaking so slowly that other people could have noticed. Or, the opposite – being do fidgety or restless that you have been moving around a lot more than usual
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Little interested or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling asleep, staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you’re a failure of have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or, the opposite – being do fidgety or restless that you have been moving around a lot more than usual
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly everyday
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly everyday
Row 1, Column 3
Not at all
Row 2, Column 0
Several days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly everyday
Row 2, Column 3
Not at all
Row 3, Column 0
Several days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly everyday
Row 3, Column 3
Not at all
Row 4, Column 0
Several days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly everyday
Row 4, Column 3
Not at all
Row 5, Column 0
Several days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly everyday
Row 5, Column 3
Not at all
Row 6, Column 0
Several days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly everyday
Row 6, Column 3
Not at all
Row 7, Column 0
Several days
Row 7, Column 1
More than half the days
Row 7, Column 2
Nearly everyday
Row 7, Column 3
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25
Calculation
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26
Hidden - PHQ Form Value
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27
Hidden - PHQ Pass/Fail
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28
Phone Number
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This field is required.
Please enter a valid phone number.
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29
Email
*
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For contact regarding this study
example@example.com
Confirm Email
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30
Would you like to be subscribed to Atlantia's database?
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Subscribing to this allows us to contact you occasionally via email with study updates or new studies
Yes, Subscribe Me
No, thank you.
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31
Consent to mailing list - hidden
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32
Where did you hear about the study?
*
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Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
Chicago Moms Network
Natural Awakenings
Other
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33
Consent to Privacy Notice
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We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com.
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34
Score
*
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35
Reason
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36
Form Status
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