Pre-Qualify

If you are ready to explore options and help doctors evaluate potential treatments for depression, consider participating in this research study of an investigational medication.
The primary purpose of the study is to test whether and investigational study medication helps improve symptoms of depression when added to an existing antidepressant medication.
Please complete our confidential questionnaire below to see if you may pre-qualify to participate in this research study for adults who are currently experiencing symptoms of depression.

Pre-Qualifying Questionnaire

To see if you may pre-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 center 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:

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

If you answered Question #6 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 Question 6 by selecting “None of these apply” or “Unsure,” please choose the first button below to indicate such. You must select one answer.

	I answered Question 6 with “None of these apply” or “Unsure”
	I have been experiencing these symptoms for less than 6 weeks
	I have been experiencing these symptoms for more than 6 weeks but less than 1 year
	I have been experiencing these symptoms for more than 1 year
	Unsure

Have you been hospitalized for depression within the past 12 months?

Yes No

Has a doctor ever told you that you have Treatment Resistant Depression?

Yes No Unsure

10.

Have you taken two or more antidepressant medications to which you had no response?

Yes No Unsure