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Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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Parent/Guardian's First Name
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Parent/Guardian's Last Name
Parent/Guardian's Phone Number
Parent/Guardian's Email Address
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Parent/Guardian's Date of Birth
Parent/Guardian's Gender
Male
Female
Other
Select all of the following that best describes you:
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
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What city do you live in?
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What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Child/Youth's First Name
Child/Youth's Last Name
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Child/Youth's Gender
Male
Female
Other
Child/Youth's Date of Birth
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Select all of the following that best describes your child/youth:
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Which of the following neurodevelopmental conditions has your child/youth been diagnosed with?
ADHD
Autism
Oppositional defiant disorder (ODD)
Conduct disorder
Tourette syndrome
Intellectual disability
Cerebral palsy
Other
None of the above
Has your child/youth ever experienced any gastrointestinal (GI) problems, such as nausea, vomiting, diarrhea, constipation, or abdominal pain?
Yes
No
Do you and your child/youth speak English or Spanish?
Yes
No
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.
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BCFS001403
