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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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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
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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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
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
Have you given birth within the last 2 weeks?
Yes
No
How many weeks gestation was your infant at birth?
Less than 26 weeks
26-30 weeks
31-34 weeks
35-37 weeks
38-40 weeks
More than 40 weeks
How many weeks along are you?
Less than 4 weeks
4-7 weeks
8-11 weeks
12-15 weeks
16-19 weeks
20-23 weeks
24-27 weeks
28-31 weeks
32-35 weeks
36-40 weeks
Which type of insurance are you using?
Private insurance
Medicaid
Medicare
TRICARE
Other
None
Please specify
Do you have plans to discontinue Medicaid health insurance during the postpartum year?
Yes
No
Are you comfortable doing the informed consent discussion and participating in the study in English?
Yes
No
Do you have a cell phone?
Yes
No
Are you willing to use your cell phone for the study?
Yes
No
Do you have plans to move outside of South Carolina in the next year?
Yes
No
Are you incarcerated or pending incarceration?
Yes
No
Are you currently institutionalized?
Yes
No
Are you enrolled in another research study with MUSC women's health?
Yes
No
Are you enrolled in Listening to Women?
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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BCFS001097
