Austin Clinical Trial Partners Social Anxiety Disorder Eligibility Questionnaire Survey

Thank you for your interest in our Social Anxiety Disorder Studies. By submitting this form you are giving consent for us to contact you regarding clinical research only. We do not sell or give away personal information to third parties.

To learn more about us, please visit www.austinclinicaltrialpartners.com

IF YOU ARE HAVING THOUGHTS OF SUICIDE OR OF HURTING OTHERS, PLEASE CALL 911 OR GO TO YOUR NEAREST EMERGENCY ROOM. FOR SUPPORT, YOU CAN ALSO CALL THE NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255 OR VISIT THEIR WEBSITE AT https://suicidepreventionlifeline.org

Question Title

* 1. Contact Information

Name

Email Address

Phone Number

Question Title

* 2. How old are you?

Question Title

* 3. Are you male or female?

male

female

Question Title

* 4. Do you live in or near Austin?

Yes

Question Title

* 5. What is your height and weight?

Height

Weight

Question Title

* 6. Check all conditions you may have or have had.

Bipolar Disorder

Depression

Schizophrenia

Post Traumatic Stress Disorder

Generalized Anxiety Disorder

Panic Disorder

Dementia

Drug Problems

Alcoholism

High Blood Pressure

Heart Problems

Diabetes

Thyroid Disease

Seizure Disorder

Severe Head Injury

Seizures

Stroke

HIV

Hepatitis B or C

Severe and uncontrolled seasonal allergies

ADHD or ADD

Poorly controlled sleep apnea

None

Other (please specify)

Question Title

* 7. Have you ever broken you nose or had nasal (nose) surgery?

Yes

Question Title

* 8. Do you have a nose piercing?

Yes

Question Title

* 9. We are required to perform drug testing for illicit (illegal) drugs, which include marijuana and other substances. Have you smoked or ingested marijuana, cannabis, hashish or any other mind-altering substance(s) in the last year?

Yes

(What did you use? When was the last time?)

Question Title

* 10. Have you taken any medications, including over the counter, herbal and prescription medications for anxiety in the last 30 days?

Yes

Question Title

* 11. Please list all medications, vitamins and supplements you are taking here.

Question Title

* 12. How did you hear about us?

Facebook

Instagram

Google Search

NextDoor

Craigslist

My doctor or therapist

Email Notification

Austin Clinical Trial Partners website

Other

Other referral (please specify)

Question Title

* 13. Have you recently had COVID, been ill, or been exposed to someone with COVID?

Yes

Question Title

* 1. Contact Information

Question Title

* 2. How old are you?

Question Title

* 3. Are you male or female?

Question Title

* 4. Do you live in or near Austin?

Question Title

* 5. What is your height and weight?

Question Title

* 6. Check all conditions you may have or have had.

Question Title

* 7. Have you ever broken you nose or had nasal (nose) surgery?

Question Title

* 8. Do you have a nose piercing?

Question Title

* 9. We are required to perform drug testing for illicit (illegal) drugs, which include marijuana and other substances. Have you smoked or ingested marijuana, cannabis, hashish or any other mind-altering substance(s) in the last year?

Question Title

* 10. Have you taken any medications, including over the counter, herbal and prescription medications for anxiety in the last 30 days?

Question Title

* 11. Please list all medications, vitamins and supplements you are taking here.

Question Title

* 12. How did you hear about us?

Question Title

* 13. Have you recently had COVID, been ill, or been exposed to someone with COVID?

Question Title

* 14. Is there anything else that you would like to tell us?