SCHIZOPHRENIA SURVEY

Thank you for your interest in our Schizophrenia 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 https://www.donaldgarciamd.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

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* 1. Please enter your last name.

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* 2. Please enter your first name and middle initial.

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* 3. Please enter your telephone number.

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* 4. Please enter your email address. If you don't have an email, just say "none".

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* 5. How old are you?

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* 6. Are you male or female?

male

female

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* 7. Do you live in or near Austin?

Yes

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* 8. Please tell us your height and weight.

How tall are you?

How much do you weigh?

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* 9. Are you currently experiencing symptoms of schizophrenia?

Yes

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* 10. Have you been diagnosed with schizophrenia?

Yes

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* 11. Are you currently taking medication for schizophrenia?

Yes

Please list all of the medication you are taking for depression, here.

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* 12. Please show how much better you feel since taking the schizophrenia medication.

0% (Not better at All)

50% better

100% (Completely better. Back to my normal self)

Clear

i We adjusted the number you entered based on the slider’s scale.

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

Bipolar Disorder

Major Depressive Disorder

Dementia

Post Traumatic Stress Disorder

Drug Problems

Alcoholism

High Blood Pressure

Heart Problems

Diabetes

Thyroid Disease

Seizure Disorder

Severe Head Injury

Stroke

HIV

Hepatitis B or C

ADHD or ADD

Other significant medical condition

None

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* 14. Have you ever been hospitalized while experiencing symptoms of Schizophrenia?

Yes

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* 15. If you answered yes, what was the date of your last hospitalization?

Date / Time

Date

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* 16. 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?)

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

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* 18. How did you hear about us?

Facebook

Instagram

Google Search

NextDoor

CraigsList

My doctor or therapist

Other

Other referral (please specify)

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* 19. Indicate whether any of these are true within the last 30 days. (check all that apply)

I have had a fever

I have had cough

I have had chest pain

I have lost sense of smell and/or taste

I have traveled outside of the Austin area

I have been exposed to someone with suspected or confirmed COVID-19 infection

I have been diagnosed with COVID-19 infection

None of the above, but I think I might have had or have COVID-19 infection

None of the above. I have not been sick

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* 1. Please enter your last name.

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* 2. Please enter your first name and middle initial.

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* 3. Please enter your telephone number.

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* 4. Please enter your email address. If you don't have an email, just say "none".

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* 5. How old are you?

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* 6. Are you male or female?

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* 7. Do you live in or near Austin?

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* 8. Please tell us your height and weight.

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* 9. Are you currently experiencing symptoms of schizophrenia?

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* 10. Have you been diagnosed with schizophrenia?

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* 11. Are you currently taking medication for schizophrenia?

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* 12. Please show how much better you feel since taking the schizophrenia medication.

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

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* 14. Have you ever been hospitalized while experiencing symptoms of Schizophrenia?

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* 15. If you answered yes, what was the date of your last hospitalization?

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* 16. 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?

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

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* 18. How did you hear about us?

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* 19. Indicate whether any of these are true within the last 30 days. (check all that apply)

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