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Eligibility Survey for Weight Loss Medication Study

Massachusetts General Hospital is recruiting girls and boys with obesity ages 12 - 18 years to study a hormonal treatment for weight loss. Participants have a 50-50 chance of receiving oxytocin, a naturally occurring hormone in the body, or placebo (inactive) nasal spray. The study medication is taken for 12 weeks. The study involves one screening visit to confirm eligibility, and 9 visits over 18 weeks. 6 of these are main visits, 3 are short check ins, and there are 5 additional check-in phone calls with a study clinician.

The main visits include: imaging tests to look at body composition, the brain, and the liver; assessments of how much energy the body burns at rest and after food; blood draws before and after a breakfast meal; nutritional analyses; and survey questionnaires about mood, behaviors, and appetite.

Visits will take place at the MGH main campus in Boston, MA. Participants will receive up to $1700 for completing the study. Local transportation and parking costs will be reimbursed.

Please complete the survey below. If you are eligible to participate in the study we will contact you shortly.

Thank you!

Are you a minor (< 18 years old) or completing this survey on behalf of someone who is a minor?

* must provide value

Yes

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Legal Name (First and Last)

* must provide value

Date of Birth

* must provide value

M-D-Y

Phone Number

* must provide value

E-mail Address

* must provide value

Mailing Address

* must provide value

Legal Name of Minor (First and Last)

* must provide value

Date of Birth of Minor

* must provide value

M-D-Y

Parent/Guardian Name (First and Last)

* must provide value

Parent/Guardian Phone Number

* must provide value

Phone Number of Minor

Parent/Guardian E-mail Address

* must provide value

E-mail Address of Minor

Mailing Address

* must provide value

How do you prefer to be contacted (ex. phone call vs. e-mail, particular days or times that are most convenient)?

What is your preferred spoken language

* must provide value

Partners HealthCare standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Partners HealthCare. If you prefer, we can send you unencrypted email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to emails sent to you from research staff in this study.

Please indicate your preference for email communication:

* must provide value

Encrypted email

Unencrypted email

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Sex assigned at birth:

* must provide value

Male

Female

Intersex

Other

Prefer not to say

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Gender identity

* must provide value

Female

Male

Transgender Female

Transgender Male

Transgender other

Genderqueer

Nonbinary

Not sure

Other Identity

Prefer not to say

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What is your current height?

* must provide value

What is your current weight?

* must provide value

What was your highest weight in the last 3 months?

* must provide value

When were you at this highest weight?

* must provide value

What was your lowest weight in the last 3 months?

* must provide value

When were you at this lowest weight?

* must provide value

Please list any prescription medications, over the counter medications, or supplements that you have taken in the last 3 months (including any forms of birth control):

* must provide value

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Do you have a current or past history of any of the following (please check all that apply). If you have not experienced any of these, please select the last option "None of the above apply":

* must provide value

Liver disease

Diabetes (Type I or Type II)

Thyroid disease

Electrolyte abnormalities

Gastrointestinal (GI) disorders

Cardiac problems

Bleeding disorders

Respiratory problems

Oral or IV steroid use

Anemia

Kidney disease

Weight loss surgery

Epilepsy

Substance use disorder

Eating disorder

None of the above apply

If you indicated a history of any of the above, or have any medical conditions not covered above, please explain:

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Please list any allergies you have (including allergies to food, medications, or latex):

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Do you have any implanted metal in your body (ex. pacemaker, aneurysm clip, surgical metal, braces/dental retainers, non-removable piercings)?

* must provide value

Yes

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Do you follow any special diet (ex. gluten-free, vegan, Paleo, Atkins, raw diet, macrobiotic diet)?

* must provide value

Yes

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Please explain your diet:

* must provide value

How did you hear about our study?

* must provide value

If you are ultimately not eligible for/interested in this study, do you give permission for us to store your information to let you know about future studies you may be eligible for?

* must provide value

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.