Major Depressive Disorder Study

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Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested? *
You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent.

Yes

First Name *

Last Name *

Phone number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code *

Are you Male or Female? *

Have you been told by a doctor that you have depression or major depressive disorder (MDD)? *

Are you currently experiencing symptoms of depression (such as a persistent feeling of sadness and loss of interest in things you normally enjoy for at least two weeks)? *

In your current depressive episode, have you taken an antidepressant medication for your depression for at least 6 weeks? *

Please note: A depressive episode is a period of two weeks or longer 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.

Was there any improvement in your depression symptoms with the antidepressant medication you are currently taking, or the one you most recently took for your current depression symptoms? *

You indicated that you experienced no or minimal improvement to the antidepressant you are currently taking or most recently took for your current depression symptoms. Was the medication you most recently took for your depression symptoms escitalopram/lexapro or citalopram/celexa? *

Have you ever been diagnosed by a doctor with any of the following psychiatric disorders? *
Select all that apply.

Bipolar disorder (or Manic Depression)

Borderline personality disorder

Antisocial personality disorder

Other personality disorder

Schizophrenia

None of the above

Unsure

Other

Have you ever been diagnosed with any psychiatric disorders not listed above? *

Are you currently diagnosed by a doctor with any of the following conditions? *
Please select all that apply.

Obsessive Compulsive Disorder (OCD)

Epilepsy

Alcohol or substance use disorder with the past 12 months (excluding nicotine)

Eating disorder (including Anorexia Nervosa and Bulimia Nervosa)

Panic disorder

None of the above

Unsure

Other

Have you ever been diagnosed with any other conditions not listed above? *

During your current episode of depression, have you been treated with ketamine, arketamine, or esketamine/Spravato? *
If you are unsure please select unsure.

Are you taking any medications for your depression or other health conditions? *

During your current episode of depression, have you been treated with Electroconvulsive Therapy (ECT) or Transcranial Magnetic Stimulation (TMS)? *
If you are unsure please select unsure.

Please, select your height from the dropdown below. *

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

If female, are you currently pregnant or breastfeeding? *

In the past 6 months, have you participated in a clinical research trial for an investigational drug? *

What is the best day/time to reach you via telephone (we know you are busy)? *

Consent for Medical Records Retrieval

By selecting “Yes” and submit below, you consent to our use and disclosure of your personal information as necessary to obtain a copy of your electronic medical records, including but not limited to your medical history, test results, treatment plans, diagnoses, prescriptions, and any other information contained in those records as necessary to provide our services to you. This medical record information will be shared with our service providers and clinical research sites in order to provide our services, including to determine your eligibility for clinical research studies. *

You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed or processed based on your consent.