Participant Information

*First Name:

*Last Name:

*E-mail:

Address:

City:

State / Zip:

*Home Telephone:

Work Telephone:

*Date of Birth (mm/dd/yy):

Medical Condition:

1. 

2. 

3. 

4. 

5. 

Are you experiencing Insomnia?

Yes No

How many hours are you sleeping a night?

Are you feeling depressed?

Yes No

Are you hearing voices that no one else can hear?

Yes No

Do you feel you have special powers?

Yes No

If so describe:

Do you have "Racing Thoughts?"

Yes No

Have you been diagnosed with any of the following?

- Schizophrenia

Yes No

- Bipolar

Yes No

- Major Depression

Yes No

- Panic Attacks

Yes No

- Obsessive Compulsive Disorder

Yes No

- Post Traumatic Stress Disorder

Yes No

- Do you smoke more than 10 cigarettes per day

Yes No

.....- Have you tried to quit in the past 3 months

Yes No

.....- If Yes, How many times

...for how long

Current Medications: