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Screening Form
Please complete the screening form below.
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First Name
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Last Name
Phone Number
Email Address
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Gender
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Female
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Date of Birth
What city do you live in?
What state do you live in?
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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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
What category 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
Are you between the ages of 30 and 55?
Yes
No
BMI question
Standard
Height
Weight
Has your weight remained relatively constant, with less than a 5% change, for the last 3 months?
Yes
No
Do you have Type 2 diabetes?
Yes
No
Are you taking insulin?
Yes
No
Have you checked your blood sugar levels (A1c) in the past year?
Yes
No
What was the value?
Do you exercise regularly?
Yes
No
Please describe what you do each week, how many times a week and the duration of each session.
Have you ever been diagnosed with heart or blood vessel, lung, liver or kidney disease?
Yes
No
Do you have any current or chronic medical problems?
Yes
No
What medications are you taking? – please list each medication and include how long you have been taking it.
Have you smoked or used nicotine in the last 6 months?
Yes
No
Are you able/willing to travel to the University of Virginia (in Charlottesville) 3X a week for 15 weeks to complete the study visits?
Yes
No
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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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BCFS00733
