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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 live in?
What state do you live in?
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Alabama
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Arizona
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California
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Delaware
Florida
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Hawaii
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Rhode Island
South Carolina
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Tennessee
Texas
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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 have a diagnosis of Fibromyalgia (FM) by a physician?
Yes
No
Do you have any other chronic pain conditions of greater pain severity than the Fibromyalgia?
Yes
No
Do you have any significant sensory, motor, or anatomic differences or injuries?
Yes
No
Do you have any known anomalies of the central nervous system (including stroke, dementia, aneurysm, or personal history of psychosis)?
Yes
No
Are you currently pregnant?
Yes
No
Do you have any major medical conditions such as kidney, liver, cardiovascular (hypertension, preexisting cardiac arrhythmia), autonomic, pulmonary, or neurological problems (e.g., seizure disorder) or a chronic systemic disease (e.g., diabetes)?
Yes
No
Do you have a history of blood clots or clotting disorders?
Yes
No
Are you currently using opiate medication(s)?
Yes
No
Do you have a history of seizures or significant fainting?
Yes
No
Do you have a history of frostbite?
Yes
No
Do you have a history of Reynaud’s phenomenon (hands get white, then blue on exposure to cold, then red on warming)?
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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BCFS00521
