Major Depressive Disorder Research Study

Full Name

Email Address

Phone Number

Date of Birth

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

City and State You Live In

Do you consent to be contacted about future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Height (in inches):

Height and weight are used to compute BMI; eligibility requires BMI between 18.0 and 35.0.

Approximate weight (in pounds):

Are you willing and able to comply with study visits, procedures, and requirements?

Yes No

Have you been diagnosed with Major Depressive Disorder (MDD) without psychotic features?

Yes No

Is Major Depressive Disorder your primary condition currently being treated?

Yes No

Are you currently experiencing a depressive episode that began at least 4 weeks ago but has not exceeded 6 months?

Yes No

Have you had a psychiatric hospitalization (inpatient or intensive outpatient) within the past 3 months?

Yes No

Have you ever been diagnosed with any of the following? (Select all that apply)

Schizophrenia or other psychotic disorder Bipolar disorder with psychotic features Dissociative disorder Neurocognitive disorder Opioid use disorder None of the above

In the past 12 months, have you been diagnosed with or treated for any of the following?

ADHD Personality disorder PTSD OCD Eating disorder (anorexia, bulimia, binge eating) Chronic fatigue syndrome None of the above

Have you ever taken medication for depression?

Yes No

If yes, please name the medication and dosage:

Have you been diagnosed with generalized anxiety disorder, social anxiety disorder, or panic disorder?

Yes No

Allowed only if MDD is your primary diagnosis.

In the past 6 months, have you had thoughts of suicide with intent or a specific plan?

Yes No

In the past 12 months, have you attempted suicide or engaged in suicidal behavior?

Yes No

In the past 12 months, have you had a moderate or severe substance use disorder (excluding nicotine)?

Yes No

Have you used opioids (prescribed or recreational) within the past 2 weeks or regularly within the past 12 months?

Yes No

Would you be willing to complete drug and alcohol testing as part of the study?

Yes No

Have you failed (had little or no benefit from) 3 or more antidepressant medications during your current depressive episode?

Yes No

Study team will review either way.

Are you currently taking any medications that you would be unable or unwilling to stop if required by the study?

Yes No

Have you received any of the following treatments in the past 12 months?

ECT TMS Ketamine or Esketamine Vagus nerve stimulation Experimental CNS treatment None of the above

Have you started psychotherapy within the past 8 weeks?

Yes No

Have you received hypnosis or acupuncture for depression within the past 4 weeks?

Yes No

Do you have any unstable or serious medical conditions?

Yes No

Have you been diagnosed with liver, kidney, heart, neurological, endocrine, or gastrointestinal disease that is not stable?

Yes No

Do you have thyroid disease that has not been stable for at least 90 days?

Yes No

Do you have conditions that may interfere with medication absorption (e.g., bariatric surgery, short bowel syndrome)?

Yes No

What is your sex at birth?

Male Female

Are you currently pregnant or breastfeeding?

Yes No

If you are of childbearing potential, are you willing to use an approved method of birth control during the study and for 30 days after?

Yes No Not applicable

If you are sexually active with a female partner of childbearing potential, are you willing to use protocol-required contraception during the study and for 30 days after?

Yes No Not applicable

Are you considering becoming pregnant, donating eggs, or donating sperm during the study or within 30 days after?

Yes No

Major Depressive Disorder Research Study – Screening Questionnaire