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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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Female
Date of Birth
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What city do you live in?
What state do you live in?
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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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
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
In the last 30 days, how many days per week have you used cannabis?
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0 days per week
1-2 days per week
3-4 days per week
5-7 days per week
How many cigarettes do you smoke per day?
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0 cigarettes
1-2 cigarettes
3-4 cigarettes
5-6 cigarettes
More than 7 cigarettes
Are you interested in quitting or reducing your cannabis/tobacco use?
Yes
No
I do not use cannabis/tobacco
Are you a veteran?
Yes
No
(Women only) Are you pregnant, nursing, or plan to become pregnant in the next 6 months?
Yes
No
N/A
(Women only) Would you agree to use acceptable forms of birth control for the duration of the trial?
Yes
No
N/A
Are you willing to consent to random assignment (randomly being assigned to the treatment group that receives the study medication, or the group that receives a placebo or dummy-drug), and be willing to commit to taking the study medication?
Yes
No
BMI question
Standard
Height
Weight
Can you understand English?
Yes
No
Do you have severe renal impairment?
Yes
No
Do you have a history of any psychotic disorder (Bipolar, Schizophrenia, etc) or take any medications prescribed for mania or psychosis?
Yes
No
Do you use any medications to treat mental health conditions (depression, anxiety, bipolar disorder, schizophrenia) with the exception of non-MAO-I antidepressants, non-benzodiazepine anxiolytics, and ADHD medications?
Yes
No
Do you take bupropion, amitriptyline, or nortriptyline?
Yes
No
Have you had a moderate or severe substance disorder other than cannabis or tobacco within the past 60 days?
Yes
No
Have you taken any experimental medications in the past 30 days?
Yes
No
Do you have any clinically significant medical disorders, lab abnormalities, or have had a clinically significant cardiovascular disease in the past 6 months (e.g., myocardial infarction, CABG, PTCA, or severe or unstable angina)?
Yes
No
Have you had any clinically significant cerebrovascular disease in the past 6 months such as TIA, CVA, or stroke?
Yes
No
Do you have a hypersensitivity to varenicline?
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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BCFS00518
