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Anxiety Study Questionnaire
Please fill out all required questions - this will help us determine your eligibility for the study. The questionnaire will take approx. 4 mins to complete
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1
Full Name
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First Name
Last Name
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2
Are you aged between 18-65?
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This is inclusive of 18 & 65
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3
Hidden - Are you aged between 18-65?
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Are you pregnant, breastfeeding or planning a pregnancy?
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N/A - Male
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5
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
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N/A - Male
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6
Do you experience symptoms of anxiety?
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Yes
No
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7
Hidden - Do you experience symptoms of anxiety?
*
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Yes
No
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8
Do you have a diagnosis of depression
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Yes
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9
Hidden - Do you have a diagnosis of depression
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10
When were you diagnosed with depression?
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11
Have you been diagnosed with any (other) medical conditions?
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e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
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12
Hidden - Have you been diagnosed with any (other) medical conditions
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e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
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13
Please specify what medical conditions you have been diagnosed with
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e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc.
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14
Are you currently taking any medications or supplements?
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e.g blood pressure/cholesterol meds, multivitamins, probiotics or prebiotics
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15
Hidden - Are you currently taking any medications or supplements?
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Yes
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16
Please specify what medications or supplements you are currently taking
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If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure
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17
Have you been diagnosed with any allergies or intolerances by a doctor or healthcare professional?
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i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose
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18
Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?
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Yes
No
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19
Please specify which allergies or intolerances you have
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i.e. seasonal, medication, or food allergies, or intolerances to gluten, lactose
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20
Please select one of the five responses from 0-4
0 - Not present . . . 4 - Very Severe
0
1
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4
Anxious mood - Worries, anticipation of the worst, fearful, anticipation, irritability.
Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness,inability to relax.
Fears - Of dark, of strangers, of being left alone, of animals, of traffic, of crowds.
Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terror
Difficulty in concentration, poor memory.
Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing
Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone
Anxious mood - Worries, anticipation of the worst, fearful, anticipation, irritability.
Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness,inability to relax.
Fears - Of dark, of strangers, of being left alone, of animals, of traffic, of crowds.
Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terror
Difficulty in concentration, poor memory.
Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing
Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone
0
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4
0
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0
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0
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4
0
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4
0
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4
0
1
2
3
4
1
of 7
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21
Hidden - Anxiety Calculation
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22
Hidden - Anxiety Form Value
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23
Hidden - Anxiety Pass/Fail
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24
Phone Number
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087/021
1234567
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25
Email
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For contact regarding this study
example@example.com
Confirm Email
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26
Would you like to be subscribed to Atlantia's database?
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If you elect to be part of our database, you may be notified of future studies that Atlantia is undertaking that may be of interest to you. All communications to our database are undertaken in accordance with our Privacy Notice available at: https://atlantiaclinicaltrials.com/privacy-notice.
Yes, Subscribe Me
No, thank you.
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27
Consent to mailing list - hidden
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28
Where did you hear about the study?
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Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
UCC
MTU
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29
Consent to Privacy Notice
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We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com. Do you consent to Atlantia Food Clinical Trials Ltd. processing the information you have provided in this for the purpose of assessing your eligibility for this trial
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30
Score
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31
Reason
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32
Form Status
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