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Screening Form
Please complete the screening form below
First Name
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Last Name
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Phone Number
Email Address
Gender
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Date of Birth
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What city do you currently live in?
What state do you currently live in?
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Alabama
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Florida
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Hawaii
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
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
Do you currently use opioids recreationally?
Yes
No
Have you been diagnosed with Opioid Use Disorder?
Yes
No
Do you use opioids intravenously?
Yes
No
Are you currently taking any of the following drugs?
Methadone
Suboxone
Buprenorphine
None of the above
Are you taking any Antidepressants, Benzodiazepines, mood stabilizers, or stimulants?
Yes
No
What type of medication are you taking?
Antidepressants
Benzodiazepines
Mood stabilizers
Stimulants
Do you have any significant substance use disorders other than nicotine or recreational opioid use?
Yes
No
Have you ever overdosed on opioids?
Yes
No
Do you have any mental or psychiatric conditions?
Yes
No
What mental or psychiatrics conditions do you have?
Have you been diagnosed with HIV?
Yes
No
Do you consent to being contacted by study teams in the future?
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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BCFS00457