Major Depression Disorder

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Would you like to be contacted about taking part in a Clinical Trial? *

Yes

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code *

What sex were you assigned at birth? *

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)? *

Have your current depression symptoms lasted longer than 2 years? *

Are you currently taking an antidepressant medication for your depression? *

Have you previously taken an antidepressant medication during your current episode of depression? *

Is this current antidepressant medication helping with the symptoms of your depression? *

Did this prior antidepressant help with the symptoms of your depression? *

Do you have a history of epilepsy or seizures, other than a single seizure? *

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

Bipolar disorder

Neurocognitive disorder

Borderline personality disorder

Antisocial personality disorder

Schizophrenia

None of the above

Unsure

Are you currently diagnosed by a doctor and experiencing any of the following disorders? *
Select all that apply.

Obsessive compulsive disorder (OCD)

Eating disorder (including Anorexia Nervosa and Bulimia Nervosa)

Panic disorder

None of the above

Unsure

Have you ever been treated with vagus nerve stimulation or a deep brain stimulation device implant for depression? *

Have you ever been treated with electroconvulsive therapy (ECT) within this current episode of depression or within the last year? *

Have you started psychotherapy (also known as talk therapy) within the last 3 months? *

Have you been diagnosed or are currently suffering from a substance (excluding nicotine) or alcohol use disorder (also known as substance or alcohol addiction) within the last 12 months? *

Do you use cannabis (also known as marijuana)? *

If yes, are you willing to refrain from using cannabis before and during the clinical trial, if you were selected to participate? *

Please list the medications you are currently taking for your depression. *
Please only include medications which have been prescribed by a doctor.
Please list here or write 'none'.

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: congestive heart failure, HIV, chronic hepatitis B or C).
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

Are you taking any medications for your other health conditions? *
Please list them below or type ‘none’.

If qualified for the study, would you be willing and able to attend weekly visits over a period of 14 weeks? *

Please, select your height from the dropdown below. *

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

If female at birth, 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

Are you currently participating in another Clinical Trial? *

What is the best day/time and method to reach you by (telephone or email) (we know you are busy)? *

The information you are providing here will only be used to match you to a clinical research study and contact you to see if you would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to autocruitment.com, or if you would like to make any changes, please contact us at info@autocruitment.com.