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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
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 chronic pain conditions have you been diagnosed with?
Trigeminal neuralgia (TN)
Post-surgical neuralgia (PSN)
Post-herpetic neuralgia (PHN)
Other chronic pain condition
None of the above
How long have you been experiencing chronic pain?
Less than 6 months
Between 6 months and 1 year
More than 1 year
Which of the following physical medical conditions have you been diagnosed with?
Asthma
Chronic obstructive pulmonary disease (COPD)
Rheumatoid arthritis
Osteoarthritis
Fibromyalgia
Chronic kidney disease
Liver disease (e.g., cirrhosis)
Inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis)
High blood pressure (hypertension)
Osteoporosis
Type 1 diabetes
Type 2 diabetes
Cardiovascular (heart) problems
Stroke
Chronic skin disease
Thyroid disease
Cancer
Other
None of the above
Which of the following neurological conditions have you been diagnosed with?
Alzheimer's disease
Dementia
Mild Cognitive Impairment (MCI)
Parkinson's disease
Epilepsy
Stroke
Multiple sclerosis
Migraine
Amyotrophic lateral sclerosis (ALS)
Traumatic brain injury (TBI)
Other
None of the above
Are you currently involved in litigation regarding your pain or do you have/are applying for a disability claim or workman’s compensation as a result of your pain?
Yes
No
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
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 currently dependent on any substances, such as alcohol or non-prescribed drugs?
Yes
No
Have you had surgery in the past 3 months?
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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BCFS001555
