Nova Mentis

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Nova Mentis-Fragile X & Psilocybin Trial

Nova Mentis-Fragile X & Psilocybin Trial

This Survey will take no longer than 10 minutes of your time to complete and is intended to asses your eligibility for this KGK Science clinical trial. This clinical trial will investigate sub-perceptual repeat dosing of Psilocybin on Behavioural and Cognitive Symptoms of Fragile X Syndrome in Adult Patients.

49Questions

HIPAA

Compliance

1
Do we have your consent to ask you some questions related to your lifestyle and medical history and to contact you regarding this study? (You can choose to leave the survey at any time)
YESNO
2
Name
First Name
Last Name
3
Email
example@example.com
4
Phone Number
Please enter a valid phone number.
5
Please indicate your preferred contact method:
Email
Text
Phone
Any of the options
6
Will you and your caregiver be available to visit KGK Science in London, ON, 6 times over a period of approximately 1 month?
YESNO
7
What was your assigned sex at birth?
Male
Female
8
Are you presently pregnant, planning to become pregnant or presently breastfeeding?
YESNO
9
Please enter your date of birth
Date
Year
Month
Day
10
Please enter your height
Please enter a number
Please Select
Please Select
Inches
cm
Metric
11
Please enter your weight
Please enter a number
Please Select
Please Select
Llbs
Kg
Metric
12
Have you been diagnosed with Fragile X Syndrome?
YESNO
13
Do you have evidence of either molecular genetic confirmation of the full FMR1 mutation (>200 CGG repeats) or the loss of function mutation of the FMR1 Gene (SNV's and deletions of the gene) that have been provided to you by a caregiver?
Yes
No
Unsure
14
Do you have an IQ between 40-85 points from a prior assessment?
Yes
No
Unsure
15
Do you have documentation that can support the IQ result?
YESNO
16
Are you able to swallow tablets or capsules?
YESNO
17
Have you had a history of alcohol or illicit drug abuse, known drug dependence, or are seeking or have sought treatment for alcohol or substance abuse related disorders within the past 12 months?
YESNO
18
Do you have a prescription for the use of cannabis products?
YESNO
19
Do you use recreational cannabis?
YESNO
20
How often do you use cannabis recreationally?
Daily or 5-7+ times a week
Regularly or 3-4 times per week
Weekly or 1-2 times per week
Monthly or 1-3 times per month
Occasionally or less than once per month
21
Will you be able to refrain from using cannabis for the duration of the study?
YESNO
22
Do you have any allergies or food sensitivities?
YESNO
23
Please list your allergies or sensitivities
24
Have you had any major surgeries in the past 3 months, or do you have a major surgery planned during the study?
YESNO
25
If yes, what type of surgery?
26
Do you have a history of or currently have any of the following medical conditions?
Diabetes Type 1 or Type 2
Seizure Disorders
Depression/Psychiatric Disorders
Schizophrenia Spectrum Disorders
Bipolar 1 or Bipolar 2
High Cholesterol
High Triglycerides
HIgh Blood Pressure
Tachycardia/Heart Rhythm Issues
History of Gastrointestinal issues (bariatric bypass surgery)
Hepatic (Liver) or Renal (Kidney) Disease
History of Cardiovascular Disease or Cardiac Conditions
History of Psychiatric Conditions
Other
27
If other, please indicate your medical condition:
28
Have you been diagnosed with major depression?
YESNO
29
Do you experience psychotic features (ex., hallucinations, delusions, psychomotor impairment, states of stupor)?
YESNO
30
How often do you experience seizures?
31
Is your medical condition currently in stable condition, that is, are you being followed by a physician and are taking prescribed medication to control your condition?
YESNO
32
Have you had a significant cardiac even in the past 6 months?
YESNO
33
Have you had a diagnosis of cancer within the past 5 years or are you currently receiving chemotherapy or radiation treatment? This does not include skin cancer (basal cell carcinoma) that has been fully excised without chemotherapy or radiation
YESNO
34
Have you donated blood in the last 30 days?
YESNO
35
Please indicate which, if any, of the following prescription medications you take:
NMDAR agonists (Ketamine, Dextromethorphan, Mematine, Amantadine)
Monoamine Oxidase Inhibitors (MAOI's- Bifemelane, caroaznone, phenelzine)
Antidepressants
Lithium
Stimulants (e.g. Amphetamine, methylphendate)
36
Do you use any other prescription medications daily?
YESNO
37
Please list your prescription medications, dose, frequency, and the reason for use:
38
Do you use any of the following over-the-counter supplements?
St. John's Wort
5-HTP
Stimulants (ephedrine)
None
39
Will you be willing to stop taking these supplements during this study if required to do so?
YESNO
40
Do you use any other over-the-counter medications or supplements or natural health products regularly?
YESNO
41
Please list your over-the-counter medications and/or supplements:
42
Would you be willing to stop taking these over-the-counter medications or supplements listed previously during the study or prior to study visits as required?
YESNO
43
Will you be willing to maintain your current lifestyle habits throughout the study, including diet, medications, supplements, exercise and avoid taking any new supplements?
YESNO
44
Have you participated in a clinical trial within the last 30 days?
YESNO
45
Please enter date the clinical trial participation ended
Date
Year
Month
Day
46
How did you hear about this study?
Facebook
Instagram
Email
Website
Radio
Google
Flyers
YouTube
Someone referred me
Other
47
Please provide the contact information for the person who referred you so we can thank them.
48
Why did you decide to apply for participation in this study?
Interested in topic being studied
Compensation being offered for participation
Have participated in clinical trials before.
Other
49
I consent to receiving communication from KGK Science Inc. and their third-party service providers via electronic mail, electronic message, telecommunications and automatic dialing-announcing device including the use of pre-recorded or synthesized voice messages.
YESNO
Should be Empty:

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