Medical Research Study to evaluate an investigational medication for those with major depressive disorder

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 research study if they qualify. If you are visiting this website for someone else, please provide this website link to them so that they may complete the questionnaire.

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

How did you hear about this research study?

Please enter your home or work zip code. This zip code will be used to locate a study clinic near you. Please provide the zip code that would be most convenient to you.

Enter 5-digit zip code

What is your date of birth?

Month
Day
Year	ex. 1954

Are you male or female?

Male Female

What is 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 90 days?

Yes No Unsure

Are you currently taking any of the following types of prescription medications: antidepressants, anticonvulsants or mood stabilizers?

Yes No Unsure

Do you currently have any of the following conditions?
(If none apply, choose “None of these apply.” At least one box must be checked.)

	Bipolar Disorder
	Attention Deficit Hyperactivity Disorder (ADHD)
	Autism
	Borderline Personality Disorder
	Antisocial Personality Disorder
	An Anxiety Disorder
	Schizophrenia
	Unsure
	None of these apply

Do you currently have or have you ever had any of the following?
(If none apply, choose “None of these apply.” At least one box must be checked.)

	Obsessive Compulsive Disorder
	Schizophrenia or any other psychotic disorder
	Bulimia or Anorexia Nervosa
	Mental Retardation, Delirium, Dementia, Amnesia or any Cognitive Disorders
	Human Immunodeficiency Virus (HIV)
	Hepatitis B or C
	Seizure Disorder
	Stroke
	Unsure
	None of these apply

10.

Which of the following symptoms, if any, are you currently experiencing?
(If none apply, choose “None of these apply.” At least one box must be checked.)

	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
	Unsure
	None of these apply

11.

If you answered the previous question by indicating that you are experiencing one or more of the symptoms listed, please indicate how long you have been experiencing these symptoms. If you answered the previous question by selecting “None of these apply” or “Unsure,” please choose the first button below to indicate such. You must select one answer.

	I answered with “None of these apply” or “Unsure” to the previous question
	Less than 4 weeks
	4 weeks or longer, but less than 8 weeks
	8 weeks or longer
	Unsure

Privacy Policy: If you pre-qualify for this research 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 research study. Except as noted above, no personally-identifiable information will be taken from you and your answers will remain confidential. We will not use your information for any purpose other than to screen you for potential participation in this research study. 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. The person in charge of privacy for this website is the Privacy Officer, who may be contacted at 6207 Bee Caves Road, Suite 288, Austin, Texas 78746 or privacy@tprausa.com to make any updates to your information or to have your information removed.

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