
Participating cities:

California Beverly Hills Chino Costa Mesa Los Alamitos Los Angeles Newport Beach Riverside San Diego Connecticut Cromwell Florida Fort Myers Ft. Lauderdale Hallandale Beach Jacksonville Beach Orlando Illinois Hoffman Estates Indiana Indianapolis Massachusetts Boston Weymouth Michigan Rochester Hills New York New York Oklahoma Oklahoma City Texas Dallas Houston Plano San Antonio

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What is a Medical Research Study?

Pre-Qualifying Questionnaire:

To see if you may qualify for this clinical research study,
please complete this Pre-Qualifying Questionnaire.

These questions are to be answered by the person who would be participating in the clinical 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 participating in the clincial research study if they qualify.

1.

How did you hear about this clinical research study?

2.

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

3.

What is your date of birth?

Month
Day
Year	ex. 1954

4.

Are you male or female?

Male Female

5.

What is your approximate height and weight without shoes?

What is your height?
Feet: Inches:

What is your weight?
lbs:

6.

Have you taken or been treated with an investigational drug within the last 6 months?

	Yes
	No
	Unsure

7.

Has a doctor ever told you that you have any of the following? (If none apply, choose “None of these apply.” At least one box must be checked.)

	Bipolar Disorder
	Panic Disorder
	Obsessive Compulsive Disorder
	Schizophrenia or any other psychotic disorder
	Bulimia or Anorexia Nervosa
	Mental Retardation, Delirium, Dementia, Amnesia or any Cognitive Disorders
	Human Immunodeficiency Virus (HIV)
	Hepatitis B or C
	Seizure Disorder
	Stroke
	Narrow Angle Glaucoma
	Unsure
	None of these apply

8.

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

9.

If you answered Question 8 by indicating that you are experiencing one or more of the symptoms listed, please indicate how long ago it was that you went two weeks or longer being mostly free of the symptoms listed in Question 8. If you answered Question 8 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 8 with “None of these apply” or “Unsure”
	Less than 8 weeks ago
	More than 8 weeks ago but less than 12 months ago
	More than 12 months ago but less than 18 months ago
	More than 18 months ago
	Unsure

10.

Based upon information provided to you by a physician, have you had any of the following conditions in the last 6 months? (If none apply, choose “None of these apply.” At least one box must be checked.)

	Attention Deficit Hyperactivity Disorder (ADHD)
	Autism
	An Anxiety Disorder
	Unsure
	None of these apply

By clicking you authorize us to proceed with the pre-screening process and to begin recording your answers. By clicking you also consent to the terms of the Privacy and Confidentiality Policy. Your name and contact information will not be associated with your answers unless you provide this information after you complete the questionnaire.

Page 1 (maximum of 3)

Privacy and Confidentiality Policy: If you pre-qualify for this research study, you will be given a choice to submit your contact information along with your answers to the preliminary questionnaire to a study center conducting this clinical research study for further evaluation. If you make the choice to submit your contact information, your contact information will only be shared with those involved with the clinical research study and will not be shared or provided to any other person or business not related to this particular clinical research study. Except as noted above, your name and contact information will not be taken from you and your answers will remain confidential. We will not use your information for any purpose other than to screen you for potential participation in this clinical research study. Your answers will be stored electronically and for auditing purposes any identifying information that you provide to us will remain stored for up to seven years. If you provide your or a friend’s/family member’s email address, the email address will not be provided to anyone other than the person to whom the email was sent as specified in this website. The person in charge of privacy for this website is the Privacy Officer, who may be contacted at 6207 Bee Cave Road, Suite 288, Austin, Texas 78746 or privacy@tprausa.com to make any updates to your information or to have your information removed.

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