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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
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
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
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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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
Have you been diagnosed with Opioid Use Disorder (OUD)?
Yes
No
Are you currently receiving methadone maintenance treatment?
Yes
No
What is your current Methadone dosage in milligrams (mg)?
Less than 30mg
Between 30-150mg
Greater than 150mg
Do you experience any long standing and/or reoccurring pain that has lasted at least 3 months?
Yes
No
Where do you experience your pain the most?
Shoulder
Neck
Back
Knee
Other
Have you ever used cannabis at any point in your life?
Yes
No
Which of the following medical conditions have you been diagnosed with?
Alzheimer's disease
Mild Cognitive Impairment (MCI)
Parkinson's disease
Epilepsy
Stroke
Multiple sclerosis
Cerebral palsy
Amyotrophic lateral sclerosis (ALS)
Traumatic brain injury (TBI)
Liver cirrhosis
Sickle cell disease
Raynauds phenomenon
Arthritis
Carpal Tunnel
Neuropathy
Other
None of the above
Do you have any of the following conditions:
Schizophrenia
Schizoaffective disorder
Psychotic bipolar disorder
Major depression disorder
Suicidal ideation and intent
None of the above
Are you prescribed any of these medications:
Antidepressants
Benzodiazepines
Mood stabilizers
None of the above
Do you use any of the following substances regularly?
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
Which of the following statements apply to your pregnancy status or experience?
Not pregnant/Not applicable
Currently pregnant
Recently gave birth
Currently breastfeeding
Planning to become pregnant in the near future
Are you allergic to any of the following?
Cannabis/cannabinoids
Sesame seeds
Butylated Hydroxytoluene (BHT)
None of the above
Are you able to physically attend the research center for 3 study visits?
Yes
No
Are you able to arrange your own ride to and from the research center?
Yes
No
Do you consent to receiving text messages in order to schedule your phone screening?
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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BCFS001019
