What is your age?

How did you hear about Carman Research?

Can you come for weekly outpatient visits at our Smyrna office for at least six weeks?   Yes  No

Please describe your symptoms (both physical and emotional).

How long have you been feeling the way you feel today?

If you are a woman, are you fertile? or pregnant? or nursing?

Have you ever had a seizure?  Yes   No

Have you ever had or do you currently have a form of cancer? Yes  No

Do you have an unstable medical illness?  Yes  No

What medication(s) or herbs are you taking?

What anti-depressants are you taking now?

Are you allergic to any medicines? Yes   No

Have you ever been treated for drug dependency or alcoholism? Yes  No

When was your last use of alcohol or any street drug?