First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code *

What sex were you assigned at birth? *

Male

Female

Prefer not to say

Have you been diagnosed (by a doctor) with depression or major depressive disorder (MDD)? *

Yes - diagnosed with depression

Yes - diagnosed with MDD

No

Unsure

Are you currently experiencing any of the following symptoms of depression? *
Please select all that apply…

Feelings of sadness and hopelessness

Fatigue / lack of energy

Change in appetite

Weight gain / weight loss

Changes in sleeping habits / lack of sleep or too much sleep

Loss of interest in activities

Lack of concentration or poor memory

Agitation / outburst / frustration

None of the above

At what age did you first start experiencing symptoms of depression? *
Please note: Symptoms of depression include persistent feeling of sadness or emptiness, loss of interest in daily activities, lack of sleep or too much sleep, lack of energy, lack of concentration, poor memory, agitation, outburst, frustration.

Before age 50

After age 50

When did your current depressive episode first start? *
Please note: A depressive episode is a period of at least two weeks in which a person experiences certain symptoms of major depression: feelings of sadness and hopelessness, fatigue, weight gain or weight loss, changes in sleeping habits, loss of interest in activities, or thoughts of suicide.

Less than 6 weeks ago

6 weeks – 12 months ago

12 months – 24 months

More than 24 months ago

Unsure

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For Example: Bipolar disorder, OCD, schizophrenia, post-traumatic stress disorder, postpartum depression, borderline personality disorder, antisocial personality disorder, panic disorder, agoraphobia, hepatitis B, hepatitis C, HIV)
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

Are you taking any medications or treatments for your depression or for any other health conditions? *
(For Example: Ativan, Metformin)
Please list them below or type ‘none’.

Please, select your height from the dropdown below. * Please select one... 4'0" 4'1" 4'2" 4'3" 4'4" 4'5" 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11"

How much do you weigh in Lbs (pounds)? *

Are you currently pregnant, breastfeeding, or planning to become pregnant? *

Yes - pregnant / breastfeeding / planning to become pregnant

No

Are you currently participating in a clinical trial for an investigational medication, therapy, or device? *

Yes No

Which racial or ethnic group(s) do you identify with? *
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Mediterranean (Greek/Italian/Portuguese/Spanish/etc)

Another race or ethnicity

I prefer not to answer

What is the best day/time to reach you via telephone? *