Cognitive Impairment in Schizophrenia Research Study

Cognitive Impairment in Schizophrenia Research Study – Screening Questionnaire

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Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1990)

City and State You Live In

May we contact you about future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Are you between 18 and 55 years old?

Yes No

Do you live in Austin, TX or are you willing to travel to Austin for the study?

Yes No

Are you willing and able to stay at the clinic for 32 continuous days?

Yes No

Have you been diagnosed with schizophrenia by a doctor?

Yes No

Have you had this diagnosis for at least 1 year?

Yes No

Have your symptoms been stable (no hospitalizations or major worsening) in the past 2 months?

Yes No

Are you currently taking only one antipsychotic medication?

Yes No

If "No", please list both medications below. An exception may apply if one is low-dose Seroquel/quetiapine up to 100 mg at bedtime.

Antipsychotic #1

Antipsychotic #2

Have you been on the same dose of your medication for at least 2 months?

Yes No

Are you currently taking any of the following? Clozapine, Cobenfy, Verapamil (Calan), Lotronex (Alosetron), Zelnorm (Tegaserod), Voberzi (Eluxadoline)

Yes No

Have you had thoughts of suicide with a plan or intent in the past 6 months?

Yes No

Have you attempted suicide in the past 12 months?

Yes No

Have you had problems with drug or alcohol abuse in the past 12 months?

Yes No

Are you willing to complete a urine drug screen?

Yes No

Height (in inches):

Study staff will confirm if height/weight qualify.

Approximate weight (in pounds):

Have you had any of the following? (Check all that apply)

Seizures Stroke Serious head injury with loss of consciousness Serious heart condition Uncontrolled diabetes Serious kidney disease Serious liver disease Cancer in the past 5 years (except minor skin cancer) None of the above

Is English your primary language?

Yes No

Have you participated in another clinical trial in the past 60 days?

Yes No

Are you a woman?

Yes No

Are you currently pregnant?

Yes No

Are you currently breastfeeding?

Yes No

If you are able to become pregnant, are you willing to use required birth control during the study?

Yes No Not applicable

Are you willing to complete cognitive testing, bloodwork, heart testing (ECG), and other study procedures?

Yes No

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