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The Center for Psychedelic Research and Therapy at UT Austin welcomes you! Thank you for your participation in this online survey.
Please complete the survey questions below.
Demographics and Contact Information
First Name
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Middle Name (if no middle name, type "NA")
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Last Name
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Do you have a referral code? (You do not need one to complete this survey, but if you have one please let us know)
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Yes
No
If given, please enter your referral code here:
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Is there a specific study that you are interested in?
Street Address (Line 1)
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Street Address (Line 2, if applicable)
State
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Zip Code
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E-mail address
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Phone Number
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Preferred method of contact (check all that apply)
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How old are you? Please enter age in years.
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What is your date of birth? (mm-dd-yyyy)
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Today M-D-Y
In what city were you born?
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In which state/province were you born?
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With what gender do you identify?
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Male
Female
Other
What is your biological sex?
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Female (no Y chromosome)
Male (1 or more Y chromosomes)
Female (no Y chromosome)
Male (1 or more Y chromosomes)
4 Are you currently pregnant or trying to become pregnant?
* must provide value
No
Yes
Would you be able to travel to the lab (located on UT campus) for in-person procedures?
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Yes
No
Are you willing and able to provide medical records and/or pharmacy records for the purposes of eligibility screening?
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Yes
No
With which race(s) do you identify? Select all that apply.
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If "Other" selected, please specify below:
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Do you consider yourself Hispanic or Non-Hispanic?
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Hispanic
Non-Hispanic
Are you employed or in school? Select all that apply.
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How are you financially supported? Check all that apply.
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If "Other" selected, please specify below:
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How much education have you completed?
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Less than high school
High school graduate
Some college
2 year degree
4 year degree
Professional degree
Doctorate
Less than high school
High school graduate
Some college
2 year degree
4 year degree
Professional degree
Doctorate
What is your dominant hand?
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Right handed
Left handed
Ambidextrous (both right and left handed)
Right handed
Left handed
Ambidextrous (both right and left handed)
If you are ambidextrous, please answer the questions below:
Always right Usually right Both equally Usually left Always left
Always right Usually right Both equally Usually left Always left
Always right Usually right Both equally Usually left Always left
Always right Usually right Both equally Usually left Always left
5. Using a knife (without fork)
Always right Usually right Both equally Usually left Always left
Always right Usually right Both equally Usually left Always left
Always right Usually right Both equally Usually left Always left
8. Using a computer mouse
Always right Usually right Both equally Usually left Always left
Are you color blind or color impaired?
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Yes
No
What type of color blindness do you have?
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Deuteranomaly
Protanomaly
Tritanomaly
Tritanopia
Can't see colors at all
Other
Deuteranomaly
Protanomaly
Tritanomaly
Tritanopia
Can't see colors at all
Other
If other, please explain.
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Do you have any hair extensions, weave, or implants?
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No
Yes
Do you have any history of epilepsy, convulsions, or seizures?
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No
Yes
If yes, please describe:
* must provide value
Do you have any tatoos (especially near the head) or "permanent makeup" (e.g., tatooed eyeliner or eyebrows)?
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No
Yes
If yes, please indicate the approximate location and size of each:
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Do you have any piercings that cannot be removed?
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No
Yes
If yes, please explain where piercings are located and why they cannot be removed:
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Do you have any metal in the body other than dental fillings (e.g., orthodontic braces, permanent retainers, joint pins, surgical metal implants, or shrapnel)?
* must provide value
No
Yes
If yes, please indicate approximate location and size of each, and date implanted):
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Do you have a pacemaker or other implanted device (e.g., IUDs, breast implants, cochlear implants, neurostimulators, or intracardiac lines)?
* must provide value
No
Yes
If yes, please describe. If you have an IUD, please indicate the name of the IUD and the material from which it is made. If another implant, please list as much of the following as possible: location, size, purpose, composition, manufacturer, date placed in body, and country of procedure.
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Have you ever worked with metal (as a machinist or as a hobby)?
* must provide value
No
Yes
If yes, please indicate exposure dates, duration, frequency, if goggles were worn, and if any eye injuries were sustained.
* must provide value
What is your native language?
* must provide value
English
Another language
If another language, please specify:
* must provide value
At what age (in years) did you learn English?
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In what language do you think the majority of the time?
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In what language do you dream in?
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Do you feel strong emotional connections to English emotion words such as "fear", "happy", and "sad"?
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Yes
No
Were you born in the United States?
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Yes
No
If no, please indicate where you were born:
* must provide value
When did you move to the United States?
* must provide value
More than 10 years ago
5 to 10 years ago
1 to 5 years ago
Less than a year ago
More than 10 years ago
5 to 10 years ago
1 to 5 years ago
Less than a year ago
Did you complete high school in the United States?
* must provide value
Yes
No
If no, please indicate where you completed high school:
* must provide value
Have you ever experienced or been part of (please check all that apply):
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Have you ever been diagnosed with any of the following? Check all that apply:
* must provide value
If yes, please provide information on date and type of injury:
* must provide value
Have you ever lost consciousness, "blacked out", or fainted after a blow to the head?
* must provide value
No
Yes, for less than 1 minute
Yes, for less than 5 minutes
Yes, for less than 10 minutes
Yes, for less than 30 minutes
Yes, for more than 30 minutes
No
Yes, for less than 1 minute
Yes, for less than 5 minutes
Yes, for less than 10 minutes
Yes, for less than 30 minutes
Yes, for more than 30 minutes
Have you ever experienced a head injury that resulted in a loss of memory from the event?
* must provide value
No
Yes, for less than 24 hours
Yes, for more than 24 hours
No
Yes, for less than 24 hours
Yes, for more than 24 hours
If yes, did you experience any other symptoms following the injury?
* must provide value
No
Yes, but no longer bothering me
Yes, and still bothering me
No
Yes, but no longer bothering me
Yes, and still bothering me
What is your approximate height (in inches)?
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What is your approximate weight (in pounds)?
* must provide value
Do you have any past or current major medical issues that you feel might interfere with your participation in the study?
* must provide value
No
Yes
If yes, please describe:
* must provide value
Have you ever suffered from any of the following medical conditions?
High blood pressure or hypertension
* must provide value
Yes
No
Diabetes
* must provide value
Yes
No
Thyroid disease
* must provide value
Yes
No
Cancer
* must provide value
Yes
No
Stroke or brain hemorrhage
* must provide value
Yes
No
Neurological disease
* must provide value
Yes
No
If yes, please provide further information on diagnosis, treatment(s) received, current status of the health condition(s), and when you suffered from the condition(s):
* must provide value
Have you ever received a "non-traditional" therapeutic intervention? Some examples of a non-traditional treatment are:
* must provide value
Yes
No
If yes, please provide the name of the treatment, the intensity (if known), frequency of administration (e.g., daily, every other day, etc.), for how long you were in treatment, and the condition or diagnosis for which it was administered.
* must provide value
Are you currently taking antidepressant medications on a daily or near-daily basis (e.g., 5 or more days per week)?
* must provide value
No
Yes
If yes, please provide the name of the medication, the dosage (if known), frequency of use (e.g., daily, every other day, etc.), for how long you have been taking it, and the condition or diagnosis for which it was taken.
* must provide value
Are you currently taking antipsychotic or mood-stabilizing medications on a daily or near-daily basis (e.g., 5 or more days per week)?
* must provide value
No
Yes
If yes, please provide the name of the medication, the dosage (if known), frequency of use (e.g., daily, every other day, etc.), for how long you have been taking it, and the condition or diagnosis for which it was taken.
* must provide value
Are you currently taking stimulant or ADHD medications on a daily or near-daily basis (e.g., 5 or more days per week)?
* must provide value
No
Yes
If yes, please provide the name of the medication, the dosage (if known), frequency of use (e.g., daily, every other day, etc.), for how long you have been taking it, and the condition or diagnosis for which it was taken.
* must provide value
Are you currently taking anti-anxiety or sleep medications on a daily or near-daily basis (e.g., 5 or more days per week)?
* must provide value
No
Yes
If yes, please provide the name of the medication, the dosage (if known), frequency of use (e.g., daily, every other day, etc.), for how long you have been taking it, and the condition or diagnosis for which it was taken.
* must provide value
Are you currently taking any opioid-type pain medications on a daily or near-daily basis (e.g., 5 or more days per week)?
* must provide value
No
Yes
If yes, please provide the name of the medication, the dosage (if known), frequency of use (e.g., daily, every other day, etc.), for how long you have been taking it, and the condition or diagnosis for which it was taken.
* must provide value
Have you ever taken psychiatric medications (such as antidepressants, anxiolytics, benzodiazapines, or antipsychotics) at any point in the past?
* must provide value
No
Yes
If yes, please describe the type of medication taken, when it was taken (approximate months and years), for how long it was taken, and the condition or diagnosis for which it was taken.
* must provide value
Have you ever been diagnosed by a medical or mental health professional with a psychiatric disorder or a mental disorder?
* must provide value
No
Yes
If yes, please indicate the psychiatric condition(s) or mental disorders with which you were diagnosed, when you were diagnosed, and whether or not you believe the diagnosis is still currently applicable.
* must provide value
Would you say that you have treatment resistant depression? This is defined as failing 2 or more pharmacological or neuromodulatory (like TMS, DBS, ECT) treatments of adequate dose and duration (at least 8 weeks for medication) for your current episode of depression.
* must provide value
Yes
No
Do you drink alcohol on a regular basis (e.g., 3 or more times per week)?
* must provide value
No
Yes
If yes, please describe the typical frequency (e.g., once per day, 5 times per week, etc.), the types of alcohol you typically drink (beer, wine, mixed drinks, hard liquor, etc.), and the typical number of drinks consumed during each drinking session:
* must provide value
In the past 3 months, has your alcohol use (if any) caused any problems for you (e.g., legal problems, work difficulties, difficulties with friends or family), have you had withdrawal symptoms when you cut down or stopped using alcohol (e.g., hands shaking, sweating, feeling agitated), or have you needed to drink significantly more alcohol to get the feeling you were looking for?
* must provide value
No/I don't drink alcohol
Yes
No/I don't drink alcohol
Yes
If yes, please describe:
* must provide value
Do you use Nicotine/ Tobacco products on a regular basis (e.g., 3 or more times per week)?
* must provide value
Yes
No
If yes, please describe the typical frequency (e.g., how many cigarettes a day (or the equivalent)), the type of nicotine/ tobacco product (e.g., chew, cigarettes', vapes, etc.) .
* must provide value
In the past 6 months, have you used/taken any psychedelic or hallucinogenic compounds? If you have "microdosed" any psychedelic or hallucinogenic compound please answer "yes."
* must provide value
Yes
No
If yes, select from the list below any compound(s) you have taken:
* must provide value
Psilocybin ("magic mushrooms," "mushrooms," or "shrooms")
LSD, lysergic acid diethylamide ("acid," "tab," or "blotter")
MDMA, methylenedioxy-methamphetamine ("molly," "ecstasy," "E," or "X")
Ketamine ("K," "special K" or "horse tranquilizer")
PCP, phencyclidine ("angel dust," or "peace pill"
Other
Psilocybin ("magic mushrooms," "mushrooms," or "shrooms")
LSD, lysergic acid diethylamide ("acid," "tab," or "blotter")
MDMA, methylenedioxy-methamphetamine ("molly," "ecstasy," "E," or "X")
Ketamine ("K," "special K" or "horse tranquilizer")
PCP, phencyclidine ("angel dust," or "peace pill"
Other
In the past 3 months, have you used another substance recreationally in such a way that your use caused problems for you (e.g., legal problems, work difficulties, difficulties with friends or family), have you had withdrawal symptoms when you cut down or stopped using the substance, or have you needed to use significantly more of the substance to get the feeling you were looking for?
* must provide value
No/I don't use substances
Yes
No/I don't use substances
Yes
If yes, please describe:
* must provide value
Are you currently in any kind of talk therapy on a regular basis (e.g., at least twice per month) where you discuss your problems with a professional provider (doctor, psychiatrist, psychologist, counselor, etc.)?
* must provide value
No
Yes
If yes, please describe the frequency of therapy, the conditions or problems for which you are currently in therapy, and how long you have been engaged in this therapy:
* must provide value
Are you currently in any kind of evidence-based therapy on a regular basis? Evidence-based forms of therapy can include but are not limited to
* must provide value
Yes
No
If yes, please describe the frequency of therapy, the conditions or problems for which you are currently in therapy, and how long you have been engaged in this therapy:
* must provide value
Are you currently on a waiting list to start a new treatment or are you expecting to begin new treatment sometime soon?
* must provide value
Yes
No
If yes, please describe what kind of treatment you are waiting to receive. Do you anticipate pursuing this treatment immediately if you are accepted off of the waitlist?
* must provide value
Have you ever participated in regular talk therapy (e.g., once a week, twice a month) at any point in the past?
* must provide value
No
Yes
If yes, please describe the frequency of therapy in the past, the conditions or problems for which you sought therapy, and how long you engaged in therapy:
* must provide value
Have you ever participated in any kind of evidence-based therapy on a regular basis? Evidence-based forms of therapy can include but are not limited to
* must provide value
Yes
No
If yes, please describe the frequency of therapy in the past, the conditions or problems for which you sought therapy, and how long you engaged in this therapy:
* must provide value
How did you come to learn about The Fonzo Lab or The Center for Psychedelic Research and Therapy?
* must provide value
Print flyer
E-mail
Referral by healthcare provider
Phone call
Web or internet search
Social media (Facebook, Instagram, etc.)
Other
Print flyer
E-mail
Referral by healthcare provider
Phone call
Web or internet search
Social media (Facebook, Instagram, etc.)
Other
If "Other", please describe:
Life Events Checklist
1. Natural disaster (for example, flood, hurricane, tornado, or earthquake)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
2. Fire or explosion
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
3. Transportation accident (for example, car accident, boat accident, train wreck, plane crash)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
4. Serious accident at work, home, or during recreational activity
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
5. Exposure to toxic substance (for example, dangerous chemicals, radiation)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
7. Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
8. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
9. Other unwanted or uncomfortable sexual experience
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
10. Combat or exposure to a war-zone (in the military or as a civilian)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
12. Life-threatening illness or injury
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
13. Severe human suffering
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
14. Sudden, violent death (for example, homicide, suicide)
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
15. Sudden, unexpected death of someone close to you
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
16. Serious injury, harm, or death you caused to someone else
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
17. Any other very stressful event or experience
* must provide value
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
Happened to me
Witnessed it
Learned about it
Not sure
Doesn't apply
PCL-5
In the past month, how much were you bothered by:
1 Repeated, disturbing, and unwanted memories of the stressful experience?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
2 Repeated, disturbing dreams of the stressful experience?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
3 Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
4 Feeling very upset when something reminded you of the stressful experience?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
5 Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
6 Avoiding memories, thoughts, or feelings related to the stressful experience?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
7 Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
8 Trouble remembering important parts of the stressful experience?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
9 Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
10 Blaming yourself or someone else for the stressful experience or what happened after it?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
11 Having strong negative feelings such as fear, horror, anger, guilt, or shame?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
12 Loss of interest in activities that you used to enjoy?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
13 Feeling distant or cut off from other people?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
14 Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
15 Irritable behavior, angry outbursts, or acting aggressively?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
16 Taking too many risks or doing things that could cause you harm?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
17 Being "super alert" or watchful or on guard?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
18 Feeling jumpy or easily startled?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
19 Having difficulty concentrating?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
20 Trouble falling or staying asleep?
* must provide value
Not at all
A little bit
Moderately
Quite a bit
Extremely
Not at all
A little bit
Moderately
Quite a bit
Extremely
Have you lost someone significant to you?
* must provide value
Yes
No
Was the significant person you lost affiliated with the military?
* must provide value
Yes
No
How many months has it been since your significant other died?
* must provide value
Do you feel yourself longing or yearning for the person who died?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you have trouble doing the things you normally do because you are thinking so much about the person who died?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you feel confused about your role in life or feel like you don't know who you are anymore (i.e., feeling like that a part of you has died)?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you have trouble believing that the person who died is really gone?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you avoid reminders that the person who died is really gone?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you feel emotional pain (e.g., anger, bitterness, sorrow) related to the death?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you feel that you have trouble re-engaging in life (e.g., problems engaging with friends, pursuing interests, planning for the future)?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you feel emotionally numb or detached from others?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you feel that life is meaningless without the person who died?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Do you feel alone or lonely without the deceased?
* must provide value
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Not at all
Slightly
Somewhat
Quite a bit
Overwhelmingly
Have the symptoms above caused significant impairment in social, occupational, or other important areas of functioning?
* must provide value
Yes
No
MASQ
1. I felt confused.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
2. I was startled easily.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
3. I felt successful.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
4. I felt worthless
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
5. I felt nauseous.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
6. I felt really happy.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
7. I felt irritable.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
8. I felt dizzy or light-headed.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
9. I felt optimistic.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
10. I felt hopeless.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
11. I felt like I was having a lot of fun.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
12. I blamed myself for a lot of things.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
13. I felt dissatisfied with everything.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
14. I felt like I accomplished a lot.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
15. I was trembling or shaking.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
16. I felt like I had a lot to look forward to.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
17. I felt pessimistic about the future.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
18. I had pain in my chest.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
19. I felt really talkative.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
20. I had hot or cold spells.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
21. I was short of breath.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
22. I felt really "up" or lively.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
23. I felt inferior to others.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
24. My muscles were tense or sore.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
25. I had trouble making decisions.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
26. I felt like I had a lot of energy.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
27. My heart was racing or pounding.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
28. I worried a lot about things.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
29. I felt really good about myself.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
30. I had trouble swallowing.
* must provide value
Not at all
A little
Somewhat strong
Strong
Extremely
Not at all
A little
Somewhat strong
Strong
Extremely
PHQ
1. Little interest or pleasure in doing things.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
8. Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
GAD
1. Feeling nervous, anxious, or on edge.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
2. Not being able to stop or control worrying.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
3. Worrying too much about different things.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
4. Trouble relaxing.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
5. Being so restless it's hard to sit still.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
6. Becoming easily annoyed or irritable.
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
7. Feeling afraid as if something awful might happen
* must provide value
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
MDQ
1. ... you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
* must provide value
Yes
No
2. ...you were so irritable that you shouted at people or started fights or arguments?
* must provide value
Yes
No
3. ...you felt much more self-confident than usual?
* must provide value
Yes
No
4. ...you got much less sleep than usual and found you didn't really miss it?
* must provide value
Yes
No
5. ...you were much more talkative or spoke faster than usual?
* must provide value
Yes
No
6. ...thoughts raced through your head or you couldn't slow your mind down?
* must provide value
Yes
No
7. ...you were so easily distracted by things around you that you had trouble
* must provide value
Yes
No
8. ...you had much more energy than usual?
* must provide value
Yes
No
9. ...you were much more active or did many more things than usual?
* must provide value
Yes
No
10. ...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
* must provide value
Yes
No
11. ...you were much more interested in sex than usual?
* must provide value
Yes
No
12. ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
* must provide value
Yes
No
13. ...spending money got you or your family in trouble?
* must provide value
Yes
No
14. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
* must provide value
Yes
No
15. How much of a problem did any of these cause you - like being able to work; having family, money, or legal troubles; getting into arguments or fights?
* must provide value
No problem
Minor problem
Moderate problem
Serious problem
No problem
Minor problem
Moderate problem
Serious problem
16. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
* must provide value
Yes
No
17. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
* must provide value
Yes
No
AUDIT
1. How often do you have a drink containing alcohol?
* must provide value
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
* must provide value
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
3. How often do you have six or more drinks on one occasion?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because of your drinking
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
9. Have you or someone else been injured becasue of your drinking?
* must provide value
No
Yes, but not in the last year
Yes, during the last year
No
Yes, but not in the last year
Yes, during the last year
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
* must provide value
No
Yes, but not in the last year
Yes, during the last year
No
Yes, but not in the last year
Yes, during the last year
QIDS-SR
1. Falling asleep:
* must provide value
I never take longer than 30 minutes to fall asleep
I take at least 30 minutes to fall asleep, less than half the time
I take at least 30 minutes to fall asleep, more than half the time
I take more than 60 minutes to fall asleep, more than half the time
I never take longer than 30 minutes to fall asleep
I take at least 30 minutes to fall asleep, less than half the time
I take at least 30 minutes to fall asleep, more than half the time
I take more than 60 minutes to fall asleep, more than half the time
2. Sleep during the night:
* must provide value
I do not wake up at night
I have a restless, light sleep with a few brief awakenings each night
I wake up at least once a night, but I go back to sleep easily
I awaken more than once a night and stay awake for 20 minutes or more, more than half the time
I do not wake up at night
I have a restless, light sleep with a few brief awakenings each night
I wake up at least once a night, but I go back to sleep easily
I awaken more than once a night and stay awake for 20 minutes or more, more than half the time
3. Waking up too early:
* must provide value
Most of the time I awaken no more than 30 minutes before I need to get up
More than half the time, I awaken more than 30 minutes before I need to get up
I almost always awaken at least on hour or so before I need to, but I go back to sleep eventually
I awaken at least one hour before I need to, and can't go back to sleep
Most of the time I awaken no more than 30 minutes before I need to get up
More than half the time, I awaken more than 30 minutes before I need to get up
I almost always awaken at least on hour or so before I need to, but I go back to sleep eventually
I awaken at least one hour before I need to, and can't go back to sleep
4. Sleeping too much:
* must provide value
I sleep no longer than 7-8 hours/nigh, without napping during the day
I sleep no longer than 10 hours in a 24-hour period including naps
I sleep no longer than 12 hours in a 24-hour period including naps
I sleep longer than 12 hours in a 24-hour period including naps
I sleep no longer than 7-8 hours/nigh, without napping during the day
I sleep no longer than 10 hours in a 24-hour period including naps
I sleep no longer than 12 hours in a 24-hour period including naps
I sleep longer than 12 hours in a 24-hour period including naps
5. Feeling sad:
* must provide value
I do not feel sad
I feel sad less than half the time
I feel sad more than half the time
I feel sad nearly all of the time
I do not feel sad
I feel sad less than half the time
I feel sad more than half the time
I feel sad nearly all of the time
6. Concentration/Decision Making:
* must provide value
There is no change in my usual capacity to concentrate or make decisions
I occasionally feel indecisive or find that my attention wanders
Most of the time, I struggle to focus my attention or make decisions
I cannot concentrate well enough to read or cannot make even minor decisions
There is no change in my usual capacity to concentrate or make decisions
I occasionally feel indecisive or find that my attention wanders
Most of the time, I struggle to focus my attention or make decisions
I cannot concentrate well enough to read or cannot make even minor decisions
7. View of myself:
* must provide value
I see myself as equally worthwhile and deserving as other people
I am more self-blaming than usual
I largely believe that I cause problems for others
I think most constantly about major and minor defects in myself
I see myself as equally worthwhile and deserving as other people
I am more self-blaming than usual
I largely believe that I cause problems for others
I think most constantly about major and minor defects in myself
8. Thoughts of death or suicide:
* must provide value
I do not think of suicide or death
I feel that life is empty or wonder if it's worth living
I think of suicide or death several times a week for several minutes
I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life
I do not think of suicide or death
I feel that life is empty or wonder if it's worth living
I think of suicide or death several times a week for several minutes
I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life
9. General interest:
* must provide value
There is no change from usual in how interested I am in other people or activities
I notice that I am less interested in people or activities
I find I have interest in only on or two of my formerly pursued activities
I have virtually no interest in formerly pursued activities
There is no change from usual in how interested I am in other people or activities
I notice that I am less interested in people or activities
I find I have interest in only on or two of my formerly pursued activities
I have virtually no interest in formerly pursued activities
10. Energy level:
* must provide value
There is no change in my usual level of energy
I get tired more easily that usual
I have to make a big effort to start or finish my usual daily activities (for example, shopping, homework, cooking, or going to work)
I really cannot carry out most of my usual daily activities because I just don't have the energy
There is no change in my usual level of energy
I get tired more easily that usual
I have to make a big effort to start or finish my usual daily activities (for example, shopping, homework, cooking, or going to work)
I really cannot carry out most of my usual daily activities because I just don't have the energy
11. Feeling slowed down:
* must provide value
I thin, speak, and move at my usual rate of speed
I find that my thinking is slowed down or my voice sounds dull or flat
It takes me several seconds to respond to most questions an I'm sure my thinking is slowed
I am often unable to respond to questions without extreme effort
I thin, speak, and move at my usual rate of speed
I find that my thinking is slowed down or my voice sounds dull or flat
It takes me several seconds to respond to most questions an I'm sure my thinking is slowed
I am often unable to respond to questions without extreme effort
12. Feeling restless:
* must provide value
I do not feel restless
I'm often fidgety, wringing my hands, or needing to shift how I am sitting
I have impulses to move about an am quite restless
At times, I am unable to stay seated and need to pace around
I do not feel restless
I'm often fidgety, wringing my hands, or needing to shift how I am sitting
I have impulses to move about an am quite restless
At times, I am unable to stay seated and need to pace around
13. My appetite:
* must provide value
There is no change in my usual appetite
Has been less than usual
Has been more than usual
There is no change in my usual appetite
Has been less than usual
Has been more than usual
I eat somewhat less often or lesser amounts of food than usual
I eat much less than usual and only with personal effort
I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat
I eat somewhat less often or lesser amounts of food than usual
I eat much less than usual and only with personal effort
I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat
I feel a need to eat more frequently than usual
I regularly eat more often and/or greater amounts of food than usual
I feel driven to overeat both at mealtime and between meals
I feel a need to eat more frequently than usual
I regularly eat more often and/or greater amounts of food than usual
I feel driven to overeat both at mealtime and between meals
Within the last 2 weeks...
* must provide value
I have not had a change in my weight
I feel smaller than usual
I feel larger than usual
I have not had a change in my weight
I feel smaller than usual
I feel larger than usual
I feel as if I have had a slight weight loss
I have lost 2 pounds or more
I have lost 5 pounds or more
I feel as if I have had a slight weight loss
I have lost 2 pounds or more
I have lost 5 pounds or more
I feel as if I have had a slight weight gain
I have gained 2 pounds or more
I have gained 5 pounds or more
I feel as if I have had a slight weight gain
I have gained 2 pounds or more
I have gained 5 pounds or more
Do you currently:
* must provide value
FOR FEMALES: Have you recently missed menstrual periods?
Yes
No
Of any mental health symptoms you may have experienced over the past month (anxiety, sadness, nightmares, difficulty sleeping, etc.) how distressing are these symptoms for you on a day-to-day basis?
* must provide value
Not experiencing any mental health symptoms
They don't really bother me
They bother me slightly
They bother me moderately
They bother me quite a bit
They really bother me a lot
Not experiencing any mental health symptoms
They don't really bother me
They bother me slightly
They bother me moderately
They bother me quite a bit
They really bother me a lot
Of any mental health symptoms you may have experienced over the past month (anxiety, sadness, nightmares, difficulty sleeping, etc.) how much do they negatively impact your social interactions and relationships on a day-to-day basis?
* must provide value
Not experiencing any mental health symptoms
They don't really impact my social interactions
They slightly negatively impact my social interactions
They moderately negatively impact my social interactions
They negatively impact my social interactions quite a bit
They really negatively impact my social interactions
Not experiencing any mental health symptoms
They don't really impact my social interactions
They slightly negatively impact my social interactions
They moderately negatively impact my social interactions
They negatively impact my social interactions quite a bit
They really negatively impact my social interactions
Of any mental health symptoms you may have experienced over the past month (anxiety, sadness, nightmares, difficulty sleeping, etc.) how much do they negatively impact your work or your ability to run errands and engage in other important activities (i.e. occupational functioning) on a day-to-day basis?
* must provide value
Not experiencing any mental health symptoms
They don't really impact my work or occupational functioning
They slightly negatively impact my work or occupational functioning
They moderately negatively impact my work or occupational functioning
They negatively impact my work or occupational functioning quite a bit
They really negatively impact my work or occupational functioning
Not experiencing any mental health symptoms
They don't really impact my work or occupational functioning
They slightly negatively impact my work or occupational functioning
They moderately negatively impact my work or occupational functioning
They negatively impact my work or occupational functioning quite a bit
They really negatively impact my work or occupational functioning
View equation View equation Not pregnant or trying to become pregnant?
View equation View equation Not predominantly left-handed by self-report?
View equation Edinburgh Handedness Inventory Revised Score
View equation Tatoos or permanent makeup?
View equation View equation View equation View equation View equation English not native language?
View equation View equation LOC for more than 10 min?
View equation Loss of memory after head injury more than 24 hours?
View equation View equation Major medical issues that might interfere w/ study participation?
View equation View equation Stroke or brain hemorrhage?
View equation View equation Current regular antidepressants?
View equation Current regular antipsychotics or mood stabilizers?
View equation View equation Current anxiolytics or sleep meds?
View equation Current opioid medications?
View equation Past psychiatric diagnosis?
View equation Past psychiatric medications?
View equation Current alcohol problems?
View equation View equation Current regular psychotherapy?
View equation Past regular psychotherapy?
View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation Likely experienced/witnessed Criterion A event or learned about it happening to someone close? Based on Life Events Checklist.
View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation Mood Disorder Questionnaire Score (MDQ Score)
View equation Likely bipolar disorder based on MDQ?
View equation View equation QIDS Weight Highest Score
View equation QIDS Psychomotor Highest Score
View equation View equation At least moderate distress due to psychiatric symptoms?
View equation At least moderate social impairment due to psychiatric symptoms?
View equation At least moderate occupational/functional impairment due to psychiatric symptoms?
View equation History of seizures, epilepsy, or convulsions
View equation View equation
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