Eligibility for Study Participation Form

Recovery from Mental Illness with Ketogenic Diets: A Qualitative Retrospective Analysis

Participant Eligibility Form

Note: You will be asked to upload mood assessments as pre-eligibility criteria. If you don't have them yet, you will want to contact your providers for a records request prior to filling out this form.

First name

Last name

Email address

Phone number

Are you an adult or an adolescent? If you are an adolescent, please have a parent or guardian fill out this form on your behalf.

Adult

18+ years of age

Adolescent

14-17 years of age

Mental Health and Ketogenic Diet History

1. Do you currently self-identify as recovered or as in the process of recovering from a DSM-V-categorized mental illness?

Yes No

Ketogenic Diet Information

Are you stable in the use of the ketogenic diet and not currently receiving regular consultation from a dietary professional?

Yes No

Did you confirm the presence of ketones as part of your ketogenic diet, at any point with either urine, blood or breathe measures?

Yes No

Mood Assessment Information

Other not listed:

Optional: For each selected assessment, please provide the before and after total scores

(example: PHQ9, before 25, after 10)

Consent for Future Contact

4. Do you consent to being contacted via secure email to provide additional information or clarification if needed?

Yes No

Upload Your Mood Assessments

Secure File Upload Please provide baseline and follow-up mood assessments. Note: If you do not have these, you must obtain them from your past or current providers in a secure manner. This may involve a records request.