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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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Male
Female
Date of Birth
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What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
What category best describes you?
OptionAmerican 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
What is your sex assigned at birth?
Male
Female
Intersex
Please provide us with your pronouns
She/her
He/his
They/them
Other
Please provide us your pronouns
Are you comfortable speaking and reading English, enough to participate in a program in English?
Yes
No
Will you be residing in the San Francisco Bay Area for the next 4 months?
Yes
No
What is your HIV status?
Positive
Negative
Unsure
What was your last CD4/T-cell count?
200 or greater CD4 count
199 to 100 CD4 count
Less than 100 CD4 count
Unsure
What is your HIV Viral Load?
200 or greater
Less than 200 (detectable)
Undetectable
Unsure
Are you currently on ART?
Yes
No
Have you ever taken pre-exposure prophylaxis (PrEP) in the last 12 months?
Yes
No
Do you currently take PrEP?
Yes
No
In the last three months, have you used methamphetamine?
Yes
No
In the last 3 months, how many days have you used methamphetamine?
Never
Once a month or less
2 days a month
3 days a month
About once a week or 4 days a month
2 days a week
3 days a week
4 days a week
6 days a week
Everyday
In the past 3 months, did you miss any ART doses due to your meth use?
Yes
No
N/A (Not on ART)
In the past 3 months, did you miss any PrEP doses due to your meth use?
Yes
No
N/A (Not on PrEP)
How interested are in you reducing your meth use?
Not at all
Slightly
Moderately
Considerably
Extremely
In the last three months, how many times have you used meth before or during anal sex (top or bottom) with men?
In the last 3 months, how many of those times were without a condom?
In the last 3 months, how many days did you drink alcohol?
Never
Once a month or less
2-3 days a month
About once a week
2-3 days a week
4-6 days a week
Everyday
How many drinks containing alcohol did you have on a typical day when you were drinking?
In the last 30 days, have you had to drink in the morning to hold off the shakes?
Yes
No
Don’t know
N/A
Are you currently taking methadone or buprenorphine?
Yes
No
Don’t know
In the last 2 wks, how often have you used opioid pain medications as prescribed?
Never
Once every two weeks or less
About once a week
2-3 days a week
4-6 days a week
Everyday
What is (are) the name(s) of the pain medication(s)?
Codeine
Codeine and acetaminophen (Tylenol No. 2, 3, 4)
Fentanyl (Abstral, Actiq, Duragesic, Fentora, Onsolis, Sublimaze)
Hydrocodone (Hysingla, Zohydro)
Hydrocodone and acetaminophen (Anexsia, Co-Gesic, Hycet, Liquicet, Lorcet, Lortab, Maxidone, Norco)
Oxycodone (Oxaydo, OxyContin, OxyIR, Roxicodone, Xtampza)
Oxycodone and acetaminophen (Oxycet, Percocet, Roxicet, Tylox, Xartemis)
Tramadol (ConZip, Ultram)
Tramadol and acetaminophen (Ultracet)
Morphine
Other
If other, what is (are) the name(s) of the pain medication(s)?
How long do you think you'll be taking it (them)?
Will not take pain meds
One week
Two weeks
Months
Years
Always
In the last 2 wks, how often have you used pain medications recreationally or not as prescribed?
Never
Once every two weeks
Once a week
2-3 days a week
4-6 days a week
Everyday
What is (are) the name(s) of the pain medication(s) you have used recreationally or not as prescribed?
Heroin
Fentanyl
Morphine
Oxycodone
Methadone
Other
N/A (have not taken pain medication recreationally)
If you didn't use this (these) pain medication(s), would you get withdrawal symptoms?
Yes
No
Unsure
N/A
In the last two weeks, did you use heroin?
Yes
No
Unsure
Do you have any known allergies to naltrexone/Revia?
Yes
No
Have you ever been diagnosed with schizophrenia?
Yes
No
Unsure
Are you currently participating in other intervention studies?
Yes
No
Are you currently in substance use treatment or self-help programs?
Yes
No
Do you currently have an active cell phone that can send and receive text-messages?
Yes
No
Are you willing to participate in a study that involves sending and receiving daily text-messages?
Yes
No
Are you willing to come into this office 8 times throughout the 16-week study?
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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BCFS00523
