Skip to content
Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
Displayed
First Name
Displayed
Last Name
Phone Number
Email Address
Displayed
What sex were you assigned at birth?
Male
Female
What gender identity do you identify as?
Male
Female
Transgender Male
Transgender Female
Non-binary
Prefer to self-describe
Please describe your gender:
Displayed
Date of Birth
Displayed
What city do you live in?
Displayed
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
Displayed
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
Other
Please describe:
Which of the following psychiatric conditions have you been diagnosed with?
Depression
Anxiety
Bipolar disorder
Schizophrenia or related condition
OCD
PTSD
Borderline personality disorder
Antisocial personality disorder
Other
None of the above
Which type of bipolar disorder have you been diagnosed with?
Bipolar I
Bipolar II
Cyclothymic Disorder or Cyclothymia
Other
Unknown/Unsure
Please describe your bipolar disorder:
Have you ever been enrolled in an abstinence-only treatment program for alcohol use issues?
Yes
No
Have you ever been enrolled in an abstinence-only treatment program for drug or substance use issues?
Yes
No
Which of the following physical medical conditions have you been diagnosed with?
Heart attack
Stroke
Cardiovascular (heart) problems
High blood pressure (hypertension)
Liver disease (e.g., cirrhosis)
Vascular disease
Inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis)
Type 1 diabetes
Type 2 diabetes
HIV
Sickle cell anemia or other blood disorders
Hepatitis C
Other
None of the above
Please describe the condition:
Do you have any limitations that would prevent you from safely undergoing an MRI scan, such as having non-removable metal objects in your body (implants, pacemakers, etc.) or experiencing claustrophobia?
Yes
No
What potential limitations do you have?
How often have you consumed 4+ drinks in one drinking occasion in the past 12 months?
0-1 times
2-3 times
4-5 times
More than 5 times
How often have you consumed 3+ drinks in one drinking occasion in the past 12 months?
0-1 times
2-3 times
4-5 times
More than 5 times
Are you currently in treatment for alcohol use?
Yes
No
Do you have any medical, religious or other reasons for not being able to drink alcohol?
Yes
No
Have you had a significant head injury or loss of consciousness that lasted more than 5 minutes?
Yes
No
Please describe your history of significant head injury or loss of consciousness:
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
When are the best times for us to contact you?
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.
Displayed
Captcha
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS001105
