First Name*: Last Name*: Phone Number*: Email*: What we do here is Clinical Research, we are doing FDA testing on medications; the studies will require you to take medications, are you willing to take a medication for our studies? NoYes The pharmaceutical companies are the ones making the rules on the study, as far as what you can or cannot have. So, to see if the study will be a good fit for you, we will need to go over several questions about your symptoms and medical history to see if you may be eligible. We are not a treatment facility. You do not have to answer any question you do not want to answer. Your information will be recorded but will only be used for this study. Are you OK with this? NoYes You may be given investigational medication or placebo as part of the trial. We will not know if you are taking the actual drug ingredients or something that will look like it but not have any active ingredients in it. Neither you nor our site will know what you are taking. Are you OK with this? NoYes Have you ever participated in a research study? NoYes Did you take study medication? NoYes YES to both: What month and year did you participate? What was the date of your last study visit? What was the study for? Where did you participate? What city do you live in? We are in Oceanside, CA, and open Monday-Thursday from 8:30 a.m. to 6:00 p.m. Will it be a problem to make visits on a weekly or biweekly basis? NoYes What is your height and weight? What is your date of birth? How did you hear about us? Have you ever seen a psychiatrist? NoYes If YES: What psychiatric diagnosis were you given? When? Have you ever been given any other diagnosis? Do you currently take, or have you ever taken any psychiatric medications? NoYes If yes, what are they for? List medication, dose, start date, and end date for current and past psychiatric medications: You may be required to discontinue some or all your current medications if you wish to participate in a research study. Are you willing to stop them, including psychiatric medications, if necessary? NoYes Here is a list of medical problems, please let me know if you have had or have any of the following medical conditions: Any history of diseases, Arthritis, Cardiovascular Disease or Heart Disease, Irregular Heart Rate or Arrhythmia, Diabetes, Hepatitis A, B, or C, Human Immunodeficiency Virus (HIV), High Blood Pressure, High Cholesterol, Eating Disorder, Sleep Apnea, or other condition: DO YOU TAKE ANY MEDICATIONS FOR ANY MEDICAL CONDITIONS? NoYes If yes, what medical condition and what medications are you currently taking? Have you EVER had a seizure, stroke, or head injury (leaving you unconscious for more than a few minutes)? NoYes If yes, date/details of event: Have you ever had cancer? If YES: What type of cancer? Date of diagnosis: Date last scan/other negative lab result: Do you currently take any pain medication for ANY REASON? NoYes If yes, what is the name and dose of the medication? How often do you take it? What type of pain is it for? When was your last dose? Are any changes in dosage expected anytime soon? (Females only) Are you currently pregnant/nursing/trying to get pregnant? NoYes If no, are you on any form of birth control? (If not) Are you sexually active and willing to use one or two forms of contraception for a study? (If yes) What forms are you willing to use? Do you have any MEDICATION ALLERGIES/SENSITIVITIES? NoYes If yes, what medications? What happens to you when you take it? Have you had any recent or planned surgeries or history of gastric bypass surgery? NoYes If YES: What did you/will you have surgery for? When was/is the surgery? Do you have a history of, or currently have a Substance Abuse/Alcohol Abuse problem? NoYes If Yes, when? How long have you been sober? What substance(s)? Do you drink? If so, how much and how often? Do you currently use, or have you ever used, any drugs like meth, cocaine or recreational or medical marijuana, even occasionally? NoYes If YES, How often? When was your last use? A negative urine drug screen is required prior to screening for most studies. I acceptYesNo Have you ever been hospitalized overnight for any psychiatric reasons (suicide attempts, etc.)? NoYes If YES: When (month and year)? How long were you hospitalized? Where? What were you hospitalized for? Any other overnight hospitalizations? Do you have a history of any suicide attempts or ideation (thoughts of suicide)? NoYes If YES: How many times did you attempt? When did you attempt? How did you attempt each time? Have you ever had any TMS treatments or shock therapy? (Electroconvulsive therapy -ECT)? NoYes Have you ever had thoughts of harming others? NoYes If YES, what kind of thought did you have? When was the last time? Select which date and time would you like us to contact you 8:00-9:00 AM PST9:00-10:00 AM PST10:00-11:00 AM PST12:00-1:00 PM PST2:00-3:00 PM PST3:00-4:00 PM PST4:00-5:00 PM PST5:00-6:00 PM PST Any additional notes or comments? *Required
