Major Depressive Disorder Research Study - Pre-Screening Questionnaire

Full Name

Date of Birth

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

Phone Number

Email Address

City and State You Live In

Preferred Contact Method

Phone Email Text Message

Best Time to Contact

Morning Afternoon Evening

Do you consent to being contacted about this and future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

What is your height? (in inches)

Enter your height in inches — for example, 5 feet 8 inches is 68 inches.

What is your weight? (in pounds)

Your height and weight are used to calculate your Body Mass Index (BMI). Study participants must have a BMI between 18 and 42 kg/m² (inclusive).

Have you been diagnosed with Major Depressive Disorder (MDD)?

Yes No

Date of diagnosis (if known)

Are you currently experiencing a Major Depressive Episode?

Yes No

When did your current episode begin?

Are you currently taking an oral antidepressant?

Yes No

Please select all medications you are currently taking — Tricyclic Antidepressants

Please select all medications you are currently taking — Selective Serotonin Reuptake Inhibitors (SSRIs)

Fluvoxamine Paroxetine Fluoxetine Sertraline Citalopram Escitalopram Vilazodone Vortioxetine

Please select all medications you are currently taking — Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Venlafaxine Venlafaxine XR Duloxetine Desvenlafaxine Milnacipran Levomilnacipran

Please select all medications you are currently taking — Other Antidepressants

Trazodone Mirtazapine Mianserin Opipramol Nefazodone Agomelatine Tianeptine Reboxetine Bupropion XL or SR (up to 300 mg/day)

Only the extended-release (XL) and sustained-release (SR) formulations of bupropion are permitted. Immediate-release formulations are not permitted.

Please list all current medications, including medications not listed above.

For each medication, include the name, start date, dose, how often you take it, and the reason for taking it.

Approximately what percentage improvement have you experienced in your depressive symptoms while taking your current antidepressant?

Enter a number from 0 to 100 (%).

Are you currently receiving psychotherapy?

Yes No

Participants may continue psychotherapy during the study. If you are receiving Cognitive Behavioral Therapy (CBT), it must have been ongoing for at least 3 months prior to study participation. New psychotherapy cannot be started during the study.

Are you currently seeing a psychiatrist, psychologist, therapist, or counselor?

Yes No

Have you previously received ketamine or esketamine?

Yes No

When did you receive ketamine or esketamine?

Did you respond to the treatment?

Yes No

Have you previously received Electroconvulsive Therapy (ECT)?

Yes No

How many ECT treatments did you receive?

Did you respond to treatment?

Yes No

Have you been diagnosed with any psychiatric conditions other than Major Depressive Disorder?

Yes No

Please select all that apply.

Please provide additional details below.

For each diagnosis, note whether it is current and whether it is treated with medication.

Do you have any current or ongoing medical conditions?

Yes No

Please describe your condition(s), whether they are current or ongoing, and any treatment you are receiving.

Do you currently use cannabis?

Yes No

Is it medically prescribed?

Yes No

Frequency of use

Have you ever been diagnosed with a substance use disorder?

Yes No

Please provide details.

Are you currently having thoughts of suicide?

Yes No

Support is available

If you are struggling or thinking about suicide, help is available right now — you do not need to be in this study to use it.

988 Suicide & Crisis Lifeline — call or text 988 (24/7, free, confidential)
Crisis Text Line — text HOME to 741741
If you are in immediate danger, call 911 or go to your nearest emergency room.

Do you have a plan?

Yes No

Do you have the means?

Yes No

Do you plan on acting on it now?

Yes No

Have you ever attempted suicide?

Yes No

Have you participated in another clinical trial?

Yes No

Investigational product, device, or vaccine name

Date study was completed

Female participants only: Are you of childbearing potential?

Yes No Not applicable

Select "Not applicable" if this question does not apply to you.

Are you willing to use contraception during your participation in this study?

Yes No

Would you be willing to sign a medical waiver allowing the study team to contact your healthcare providers and obtain medical records to verify your diagnosis?

Yes No

Provider Name (if known)

Provider Phone Number (if known)