Pre-Qualifying Questionnaire

To see if you may qualify for this medical research study,
please complete this Pre-Qualifying Questionnaire.

These questions are to be answered by the person who would be enrolled in the study if they qualify. If you are visiting this website for someone else, please provide this website link to them so that she or he may complete the questionnaire.

As used in these questions, "you" or "your" refers to the person who would be enrolled in the study if they qualify.

Please enter your home zip code or postal code.

Enter 5-digit zip code

What is your date of birth?

Month
Day	ex. 08
Year	ex. 1954

What is your gender?

Female Male

Please enter your approximate height and weight without shoes.

What is your height?
Feet: Inches:

What is your weight?
lbs:

Have you taken or been treated with an investigational drug within the last 3 months?

Yes No Unsure

Which of the following symptoms, if any, are you are experiencing? (Please choose at least one answer.)

	Depressed mood (such as feelings of sadness or emptiness)
	Reduced interest in activities that used to be enjoyed
	Sleep disturbances (either not being able to sleep well or sleeping too much)
	Loss of energy or the onset of fatigue
	Difficulty concentrating, holding a conversation, paying attention, or making decisions
	Thoughts of worthlessness or guilt
	A considerable loss or gain of weight
	Behavior that is agitated or slowed down
	None of these apply
	Unsure

How did you hear about this study?

Privacy Policy: If you pre-qualify for this study, you will be given a choice to submit your contact information along with your answers to the questionnaire to a study clinic conducting this study. If you make this choice, your information will only be shared with those conducting the medical research study and will not be shared or provided to any other person or business not related to this particular study. Except as noted above, no personally-identifiable information will be taken from you and your answers will remain confidential. If you provide your or a friend´s/family member´s email address, the email address will not be provided to anyone other than the person to whom the email was sent as specified in this website.

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