BCFS00519-USC-Smith-BingeEatingDisorder [Screening Form] -

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

Date of Birth

What city do you live in?

What state do you live in?

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

Are you between the ages of 18 and 64 years old?

Yes

What is your weight in pounds? What is your height in feet and inches?

BMI question

Standard

Height

Weight

During the past month have there been times when you have eaten what other people would regard as an unusually large amount of food (e.g., a pint of ice cream) given the circumstances?

Yes

During the times when you ate an unusually large amount of food, did you experience a loss of control (e.g., felt you couldn't stop eating or control what or how much you were eating)?

Yes

How many times per week on average over the past month have you eaten an unusually large amount of food and experienced a loss of control?

Less than once per week

Once per week

2-3 times per week

3-5 times per week

More than 5 times per week

Please provide an example of what you would eat during a typical episode:

Do you have ownership of a personal smartphone and are you willing to use it for the duration of the study?

Yes

Are you willing to complete a fMRI at USC on a weekday?

Yes

Do you have any of the following: cardiac pacemaker, implanted cardiac defibrillator, carotid artery vascular clamp, neurostimulator, cochlear implant, metal fragments (including shrapnel) in the head, eyes, or skin, vascular stent, ocular implant, penile implant, vascular filter for clots (including Greenfield, Umbrella, or Birds Nest filters)?

Yes

In order to prevent weight gain or counteract the effects of eating, over the past 3 months, how many times PER MONTH have you made yourself vomit?

In order to prevent weight gain or counteract the effects of eating, over the past 3 months, how many times PER MONTH have you used laxatives or diuretics?

In order to prevent weight gain or counteract the effects of eating, over the past 3 months, how many times PER MONTH have you fasted (skipped at least 2 meals in a row)?

In order to prevent weight gain or counteract the effects of eating, over the past 3 months, how many times PER MONTH have you engaged in more intense exercise specifically to counteract the effects of overeating?

Do you have a history of claustrophobia?

Yes

Do you have a history of neurological disorder/injury or intellectual disability?

Yes

Do you have a history of bariatric surgery?

Yes

Are you currently pregnant or breastfeeding?

Yes

Which hand do you write with?

Left

Right

Ambidextrous

Do you have visual impairments that won't allow you to view the screen inside the scanner without glasses?

Yes

Are you also interested in being contacted about participating in future research studies at USC?

Yes

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

Screening Form

Displayed

Displayed

Hidden

Displayed

Displayed