22HLCCP01- Halucenex Study

1

You are free to stop this pre-screen survey at any time. Do we have your consent to ask you questions related to your lifestyle and medical history and to contact you regarding this study?If no, this survey will end.

YESNO

2

Name* This field is required.

First Name

Last Name

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Email* This field is required.

example@example.com

5

How did you hear about this study?Please fill in the box below

6

Are you currently enrolled in any other clinic trial?

YESNO

7

What is your date of birth?

Date

8

Where are you located?Please enter you location in box below

9

This study will require a minimum of 7 in-person of roughly 3 weeks in Windsor, Nova Scotia. Will you be able to attend those visits (travel costs reimbursed)?* This field is required.

YESNO

10

This study will require blood and urine samples for health screening, a physical with ECG, and remaining on-site with study staff for 2 dosing visits that are approximately 8 hours long, is that suitable to you?* This field is required.

YESNO

11

Do you currently have a diagnosis of PTSD?* This field is required.

YESNO

12

Hare you previously been treated for PTSD?

YESNO

13

Are you still experiencing significant symptoms despite having treatment?

YESNO

14

Have you had 3 months of prior selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) treatment? (i.e., Paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor))

YESNO

15

If Yes, what medications were you prescribed?

16

Have you had at least 4 months of psychotherapy for PTSD?

YESNO

17

What other treatments have you had for PTSD if any?Please list below

18

Are you currently taking any medications or supplements?

YESNO

19

Please list the medication and supplements

20

Are you currently taking St. John's wort or 5-HT?

YESNO

21

Are you willing to stop taking St. John's wort or 5-HT during this trial?

YESNO

22

Do you drink coffee? (i.e., one serving of coffee equals 1 shot of espresso, 6ox (medium) coffee etc)

YESNO

23

Are you comfortable refraining from drinking coffee during dosing in the trial? (7 hours)

YESNO

24

Do you smoke cigarettes?

YESNO

25

Are you comfortable refraining from cigarettes for a period of 7 hours?

YESNO

26

Do you use cannabis frequently?

YESNO

27

Are you comfortable with refraining from cannabis for a period of around 7 hours?

YESNO

28

Do you drink alcohol frequently (More than 2-3x a week)?

YESNO

29

Are you comfortable refraining from consuming alcohol for a period of around 7 hours?

YESNO

31

Please indicate other disorder you have been diagnosed of:Fill in box below

32

Do you have an easing disorder such as anorexia, bulimia, or binge eating disorder?

YESNO

33

In the last 30 days, have you experienced a weight change of +/- 5 kg (11 lbs) due to your eating disorder (i.e., binging, purging, or restraining)

YESNO

34

Would you consider you eating disorder to be currently under control?

YESNO

35

Do you have the following:

Seizures Disorders

Hypertension

Diabetes

Any type of substance abuse or dependence? (Alcohol or Drugs)

36

Please indicate the severity of the seizure disorder (date of last seizure, current medications and whether seizure disorder is well-controlled)

37

Is your hypertension currently controlled? (i.e., with medication or lifestyle changes that result in normal blood pressure readings)

YESNO

38

Is your diabetes currently well-controlled? (i.e., your condition is currently stable due to effective medication and/or lifestyle changes)

YESNO

39

Have you ever used any psychedelic drugs? (i.e., psilocybin, LSD, peyote, mescaline, DMT, MDMA, etc.)

YESNO

40

Will you be willing to stop using psychedelic drugs during the entire study period?

YESNO

41

Has it been 30 days since your last use of psychedelic drugs?

YESNO

42

Are you willing to stop the psychedelic drugs for 30 days and rescreen after discontinuing their use for 30 days?

YESNO

43

Date of Last Use

Date