Form - Escitalopram – DIMA Health Technology Inc.

This is a survey for getting your Escitalopram!

Please fill this questionnaire to complete your order.

Please enter your first name:

Please enter your last name:

Please enter your email:

What was your sex assigned at birth?

Male

Female

How old are you?

Have you been diagnosed with depression or anxiety before by a doctor or nurse practitioner?

Yes

No

Which prescription medicines have you used in the past? Select all that apply to you. Please be aware, we don't prescribe benzodiazepines like Xanax, Ativan, Valium, Klonopin or mood stabilizers like Lithium, Lamictal, Depakote or Seroquel.

Did you experience any side effects with previous treatments that would stop you from using them again?

No, never taken any medicines before

No, never had side effects that bothered me

Yes

Over the past two weeks, how often have you been bothered by - Little interest or pleasure in doing things?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Feeling down, depressed, or hopeless?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Trouble falling or staying asleep, or sleeping too much?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Feeling tired or having little energy?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Poor appetite or overeating?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Feeling bad about yourself—or that you are a failure or have let yourself or your family down?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Trouble concentrating on things, such as reading the newspaper or watching television?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Moving or speaking so slowly that other people could have noticed; or the opposite—being so fidgety or restless that you have been moving around a lot more than usual?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Thoughts that you would be better off dead or of hurting yourself in some way?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Feeling nervous, anxious, or on edge?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Not being able to stop or control worrying?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Worrying too much about different things?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Trouble relaxing?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Being so restless that it's hard to sit still?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Becoming easily annoyed or irritable?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Feeling afraid as if something awful might happen?

Not at all

Several days

More than half of the days

Nearly every day

Have you ever been diagnosed with bipolar disorder or manic depression, even if you weren't treated for it?

Yes

No, but there is a family history of bipolar or manic depression

No

Have you ever had over 1 week of just racing thoughts, decreased need for sleep, reckless behavior or euphoric or irritated mood not due to drugs?

Yes

No

Have you ever been diagnosed with any of the following medical conditions, even if you weren't treated for it? Select all that apply to you.

If you selected any of the previous conditions please tell us when you were diagnosed and is it under control?

Have you been diagnosed with any of the following medical conditions which can impact the medicines we prescribe? Select all that apply to you.

Are there any other medical conditions that you have that we didn't ask about? Write it down here.

Is there a family history of mental health disorder (depression, anxiety, bipolar, etc.) or substance abuse (alcoholism or drug use)? Select all that apply to you.

Yes, mental health disorder

Yes, alcohol or drug use

I'm not sure

None

Has there been any changes in your work, home life, or general health (ie. new medical conditions, pregnancy, breastfeeding)?

Yes

No

If you selected "Yes", please share more information about the changes?

You're almost done! First, we need to know if you have ever been hospitalized or in the emergency department for your depression or anxiety?

Yes

No

If you selected "Yes", when was it? How long were you there for? Any other times?

Do you smoke or use other tobacco products? Select all that apply to you.

Yes, 1 pack per day or more

Yes, less than a pack per day

No, I quit

Never smoked

Other tobacco products

Do you currently drink alcohol or alcoholic beverages?

Yes, drink up to 1 drink a day

Yes, drink up to 2 drinks a day

Yes, more than five drinks at one time for five days in a row at some point over the past 30 days

No. I don't drink

Do you use drugs? This includes using needles, marijuana, ecstasy (MDMA), stimulants, uppers, etc.

Yes - Marijuana, THC, or CBD

Others - cocaine, methamphetamine, or heroin

No

It can be life-threatening to take prescription medicines for depression or anxiety if you are taking any of the following medicines. Instead, you should see a health care provider in person and not use our service. Select all that apply to you.

Are you allergic to any medicines? If yes, please list them below.

Are you currently taking any prescription medicines? If yes, please list them below.

Finally, is there anything else you'd like to share with us? How you identify, pronouns used.

Thank you for filling the form!

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