Phone Screen - Clinical Enrollment, LLC

First Name

Last Name

Email

Are you (your loved one) at least 41 years of age, and no more than 80 years old?

Yes
No

Date of Birth (MM/DD/YYYY)

Do you/they have a clinically confirmed diagnosis of Parkinson’s disease, and experience motor (movement) symptoms?

Yes
No

How long ago were you/they diagnosed or when did first movement symptoms begin?

In the last 4 years (less than 48 months)
More than 4 years ago

Are you/they currently being treated with Parkinson’s-related medications?

Yes – Levodopa
Yes – Other non-Levodopa Medication
No Medication

*NOTE: A subject that has received a levodopa challenge with a daily levodopa dose no greater than 450 mg for no longer than six weeks to diagnose their condition is not excluded if the levodopa exposure ended at least 3 months prior to screening. Any subject who failed levodopa challenge will be excluded from the study.

Which ones, at what frequency or dosage, and for how long?

Have you/they taken a dopamine receptor agonist (other than levodopa) for motor (movement) symptoms?

Yes
No

*NOTE: These medications are prohibited during the study. Prior use of a monoamine oxidase B (MAO-B) inhibitor (such as selegiline, rasagiline, safinamide) is permitted if discontinued 6 weeks prior to screening.

a 12 Which

Did your doctor tell you that you have familial Parkinson’s after receiving the results from a genetic test?

Yes
No

Do you/they have a history of (or plan to have) Deep Brain Stimulation (DBS) or other neurosurgery specific to PD upcoming in the next 6 months?

Yes
No

Are you/they insulin or GLP-1 dependent?

Yes
No

Have you/they been diagnosed with mild cognitive impairment (MCI) or dementia, or are suspected to suffer from it?

Yes
No

Do you/they have a history of epilepsy or seizure disorder requiring ongoing treatment, or have experienced a seizure or loss of consciousness within the past 12 months?

Yes
No

Do you/they have a history of severe heart failure, heart attack, stroke, transient ischemic attack (TIA), breast cancer or cancer requiring systemic therapy in the last 5 years or breast cancer ever, or HIV, or Hepatitis?

Yes
No

Do you/they have a history or current evidence of schizophrenia, bipolar disorder, major depressive disorder, or suicidal ideation?*

Yes
No

For any answer of yes please provide the following: “If you are having suicidal thoughts or feel you are in a crisis, call 9-1-1 to be connected to local emergency services. You can also present to your local emergency room, or a healthcare provider. You can also call or text the National Suicide & Crisis Lifeline at 9-8-8 or 1-800-273 TALK (8255)”

Are you/they willing to commit to attending all study visits for the duration of the trial, which lasts approximately 20 weeks?

Yes
No