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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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Parent's First Name
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Parent's Last Name
Parent's Phone Number
Parent's Email Address
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Parent's 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
Child's First Name
Child's Last Name
Child's Date of Birth
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Child's Sex at Birth
Male
Female
Intersex
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Select all of the following that best describes your child:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Which ethnicity best describes your child?
Hispanic or Latino
Not Hispanic or Latino
In the past 10 weeks, has your child experienced pain that led you to seek medical care?
Yes
No
When did your child's pain first start?
Please select the option that best describes your child's pain:
My child sought care for a new injury
My child sought care for a new onset pain condition (ex. new headaches, stomach aches)
My child sought care for pain related to a known and pre-existing condition or illness
My child sought care for pain related to a recent surgery
My child sought care for a chronic pain condition (i.e., a pain problem that has been present for more than 3 months)
Other (Please Specify)
Please specify:
Does your child continue to have pain in that area at least one day per week?
Yes
No
On a scale of 0 to 10, how intense is your child's usual pain? [0= no pain at all, 10 = worst pain imaginable]
0
1
2
3
4
5
6
7
8
9
10
Does your child have a scheduled surgery for their pain?
Yes
No
Are you expecting or involved in a litigation or compensation claim related to your child's pain?
Yes
No
Which of the following neurodevelopmental conditions has your child been diagnosed with?
ADHD
Autism
Oppositional defiant disorder (ODD)
Tourette syndrome
Intellectual disability
Cerebral palsy
Other
None of the above
Which of the following physical medical conditions has your child been diagnosed with?
Juvenile Rheumatoid Arthritis
Fibromyalgia
Inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis)
Type 1 diabetes
Cardiovascular (heart) problems
Cancer
Sickle cell anemia
Spina Bifida
Other serious chronic illness
None of the above
Do you have a personal smartphone, computer or tablet that you can use to participate in this study?
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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BCFS001215
