Cal Neuro - Multi-Sponsor - MDD Intake - MDD

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fbc

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ad_id

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adset_id

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campaign_id

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Full Name* This field is required.

First Name

Last Name

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Email Address* This field is required.

example@example.com

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Phone Number* This field is required.

Please enter a valid phone number.

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Age* This field is required.

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Gender (at birth)* This field is required.

Male

Female

Prefer not to say

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Date of Birth* This field is required.

Date

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Date of Birth* This field is required.

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Diagnosis of Major Depressive Disorder (MDD) (please specify)* This field is required.

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Current episode (Duration in weeks)* This field is required.

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Baseline MADRS score* This field is required.

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CGI-S score* This field is required.

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Current Treatment Status* This field is required.Select all that apply

Currently taking an antidepressant

Electro-Convulsive Therapy

Therapy

No Treatment

Other

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Contraception agreement* This field is required.

You agree to use highly effective contraception

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Height* This field is required.In Inches

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WeightIn lbs

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History Of Health (please select any that apply)* This field is required.

Lifetime history of bipolar disorder, schizophrenia, or schizoaffective disorder

Current diagnosis of obsessive-compulsive disorder or eating disorder

History of treatment-resistant depression (failure of ≥2 adequate antidepressant trials in current episode)

Known or potential substance use disorder within the past 6 months

Significant medical illness or unstable condition that may interfere with study

Known hypersensitivity to study drugs or formulation components

Current use of antipsychotics or mood stabilizers

Suicide ideation

None

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Additional medical history or notes