Generalized Anxiety Disorder (GAD) Study

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Yes

First Name *

Last Name *

Phone number *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code *

Are you Male or Female?

Have you been diagnosed by a doctor with Generalized Anxiety Disorder (GAD)? *

Do you experience any of the symptoms listed below? *
Please select all that apply…

Difficulty controlling feelings of worry

Feeling restless / wound-up / on edge

Difficulty concentrating

Fatigue

Irritability

Trouble falling asleep or staying asleep

Headaches / muscle aches / stomach aches

Other symptoms of Anxiety

None of the above

Have you been diagnosed (by a doctor) with any of the additional psychiatric medical conditions? *

Schizophrenia

Bipolar disorder

Obsessive Compulsive Disorder (OCD)

Borderline or antisocial personality disorder (BPD)

None of the above

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: Neurocognitive disorder, major depressive disorder (MDD), autism spectrum disorder (ASD), attention-deficit/hyperactive disorder (ADHD), dyslexia, cerebral palsy, cyclothymic disorder, neuroleptic malignant syndrome, serotonin syndrome, pituitary tumor, HIV, type 1 diabetes)
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 Generalized Anxiety Disorder (GAD) or other health conditions? *
(Examples include: Lexapro, Adderall, Lorazepam, Prozac, Sertraline, Propranolol, Escitalopram, Vagus Nerve Stimulation, Transcranial Magnetic Stimulation (TMS), Neuromodulation, Electroconvulsive therapy (ECT), Ketamine, Esketamine, Arketamine, Psilocybin, MDMA)
Please list them below or type ‘none’.

Have you previously had an allergic reaction to a medication? *

Please, select your height from the dropdown below. *

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

If female, are you currently pregnant or breastfeeding? *

Which racial or ethnic group(s) do you identify with? *
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

Another race or ethnicity

I prefer not to answer

What is the best day/time to reach you via telephone between the hours of 8am-5pm? *

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. By providing your phone number and clicking “Submit” below, you consent to receive messages, including SMS/MMS text messages, sent by or on behalf of AutoCruitment, with information about research studies for which you may be eligible. By clicking Submit, you also agree to our SMS Terms. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.