BCFS001252-Yale-KrishnanSarin-AUD[Screening Form] -

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

HIC#2000029675

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First Name

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Last Name

Phone Number

Email Address

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Gender

Male

Female

Other

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Date of Birth

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What city do you live in?

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What state do you live in? Select

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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

For the next question, please use the below image as reference:

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On average, how many alcoholic beverages do you typically consume per week?

How many alcoholic beverages do you typically consume per week on average?

Are you pregnant or attempting to become pregnant?

Yes

Are you currently in treatment for alcohol use?

Yes

Which of the following substances do you regularly use?

Nicotine (e.g., cigarettes, vaping)

Cannabis

Stimulants (e.g., cocaine, methamphetamine, ecstasy)

Depressants (e.g., tranquilizers, benzodiazepines)

Opioids (e.g., heroin, prescription painkillers)

Hallucinogens (e.g., LSD, psilocybin)

Inhalants (e.g., solvents, aerosols)

Other

None of the above

Do you have any major or unstable medical conditions?

Yes

Are you able to read and write English?

Yes

Are you able and willing to travel to New Haven for study appointments?

Yes

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Tagged BCFS001252