Clinical Trial Eligibility Questionnaire

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

utm_source

Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

SiteId

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Have you ever been diagnosed with, or are you currently being treated for, any of the following mental health conditions? (Select all that apply)

Have you been diagnosed with depression?

How long has your current depression lasted?

Are you currently taking antidepressant therapy (ADT), and if so, what percentage of improvement do you attribute to your current treatment?

If you are not currently taking antidepressant therapy (ADT), have you ever tried ADT for a current or past depressive episode, and if so, how many different antidepressant medications have you tried?

Have you received any of the following treatments within the last five (5) years? Electroconvulsive Therapy (ECT), Vagus Nerve Stimulation (VNS), or Deep Brain Stimulation (DBS).

Have you ever been diagnosed with epilepsy, not including seizures you had only as a child?

Have you been diagnosed with bipolar depression?

Has your current depressive episode lasted at least two months?

Have you ever had a manic or hypomanic episode?

Which medications are you currently taking for bipolar depression? (Select all that apply)

Do you have a history of Gastric Bypass Surgery:?

Do you currently use nicotine (such as smoking, vaping, or other nicotine products)?

Are you currently in therapy or counseling?

Have you taken any medications for mental health in the last two months?

Which of the following situations cause you discomfort or anxiety? (Select all that apply)

Have you been diagnosed with schizophrenia for at least one year?

Are you currently having any of the following issues with your schizophrenia medication? (Select all that apply)

Do you have stable housing and a reliable person (such as a family member, friend, caregiver, nurse, or social worker) who can support you if needed?

Have you ever been diagnosed with any of the following conditions, or taken the medication clozapine?

Have you ever had surgery on your stomach or intestines (such as having part removed), or do you currently have an active stomach ulcer or ulcerative colitis?

Depression Eligibility Status

Bipolar Eligibility Status

Social Anxiety Eligibility Status

Schizophrenia Eligibility Status

Eligibility Status