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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?
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
What is your Biological Sex (as assigned on your birth certificate)?
Male
Female
Do you receive primary care regularly?
Yes
No
Have you ever experienced a potentially traumatic event, such as a situation that involved death, serious injury, sexual violence, or a life threat to yourself or others?
Yes
No
Did this traumatic event that you experienced occur in the last 3 months?
Yes
No
In the past month how many times have you experienced nightmares?
Never or once
2 to 3 times in the last month
Once or twice a week
Several times a week
Daily or almost every day
How much distress do the nightmare(s) cause you?
Mild- minimal distress, may not have awoken
Moderate- awoke in distress but readily returned to sleep
Severe- considerable distress, difficulty returning to sleep
Extreme- incapacitating distress, did not return to sleep
Are you a military Veteran?
Yes
No
Are you willing to give the study team access to your medical records?
Yes
No
Have you received care at a VA facility in the last two years?
Yes
No
Do you have regular internet access at home and a computer or tablet with working video camera capability?
Yes
No
Do you have a smartphone on which you can download apps?
Yes
No
Will you have a stable address for the next 4 months?
Yes
No
(If female) Would you be willing to use effective forms of contraception?
Yes
No
N/A
Do you have sleep apnea?
Yes
No
Are you currently using treatment for your sleep apnea as instructed by your healthcare provider (i.e. using a CPAP device or other Sleep Apnea treatment device)?
Yes
No
Are you able to physically attend the research site for study visits or remotely attend visits via video calls for approximately 9.5 weeks? NOTE: Participants can opt to participate remotely in study visits. Also, remote participation may be required due to COVID-related rules at the medical center. Approval from the study doctor is needed for remote participation. Any study material mailed to the participants would be needed back. The study team will provide a prepaid return mailer. Participants may have to drop off packages to send back to the study team at their local UPS, FedEx, USPS, etc
Yes
No
Do you have any of the following medical conditions? Please check all that apply:
Stroke in the last 2 years Multiple sclerosis
A seizure disorder
Other chronic neurologic condition
Dementia or Alzheimer’s disease
Parkinson’s disease
Myasthenia gravis
Brain aneurysm
Brain cancer
Other neurological disorder that is significantly impacting your ability to move or carry out your daily activities
None of the above
Have you been diagnosed with any of the following?
High blood pressure (Hypertension)
Low blood pressure (Hypotension)
None of the above
Do you have a history of any of the following heart problems?
Heart attack in the past year
Congestive heart failure
Enlarged heart or cardiomyopathy
Aortic aneurysm
Abnormal heart rhythm
Abnormal EKG (common test that records electrical signals of your heart)
Chest pain or angina in past 6 months
Other chronic heart condition
None of the above
Do you have any of the following health conditions or receive any of the following treatments:
Kidney disease
Liver disease
Cirrhosis
Cancer that is not currently in remission
Frequent falls? By frequent, we mean falling more than every 3 months
Any other chronic health conditions that you believe could prevent you from taking a study drug?
None of the above
Are you currently taking any of the below medications? Please check all that apply:
SSRIs (e.g., fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram. (Celexa) and escitalopram (e.g., Lexapro))
Duloxetine (e.g., Cymbalta)
Bupropion (e.g., Wellbutrin, Zyban)
Mirtazapine (e.g., Remeron)
Venlafaxine (e.g., Effexor)
None of the above
Assuming your healthcare provider is okay with this, are you able and willing to take a stable dose of this medication(s) for the duration of the study period? (9.5 weeks) NOTE: The study team would not ask you to alter treatments recommended by your healthcare provider.
Yes
No
N/A
Are you currently using any of the following medications: Boceprevir (Victrelis) or Midodrine (ProAmatine)?
Yes
No
Are you currently using any of the following medications? ● Trazodone ● Prazosin ● Yohimbine ● Ma huang ● Sildenafil (Viagra), tadalafil (Adcirca, Cialis), vardenafil (Levitra, Staxyn) or avanafil (Stendra)
Yes
No
Assuming your healthcare provider is okay with this, are you willing to stop using these medications throughout the duration of the study as instructed by the study team?
Yes
No
N/A
Do you have any history of a bad reaction to any of the following medications: prazosin, doxazosin (Cardura), tamsulosin (Flomax), terazosin or alfuzosin?
Yes
No
If male: Have you ever experienced an episode of priapism which is a prolonged and painful erection that requires medical attention to treat?
Yes
No
N/A
Are you currently in one of the following therapies that specifically focuses on processing trauma or nightmares: cognitive processing therapy (CPT), prolonged exposure therapy (PE), or imagery rehearsal therapy (IRT)?
Yes
No
Has a healthcare provider diagnosed you with mania or bipolar I disorder?
Yes
No
Unsure
Have you had a manic episode in the past 5 years?
Yes
No
Has a healthcare provider diagnosed you with a psychotic disorder or psychosis?
Yes
No
Unsure
Have you experienced symptoms of this disorder in the past 5 years? (some symptoms include having hallucinations or delusions)
Yes
No
Unsure
In the past three months, how often did you have a drink containing alcohol?
Never
Once per month or less
Two to four times per month
Two to three times per week
Four or more times per week
In the past month, how often did you have a drink containing alcohol?
Never
Once
Once a week or once every other week
Two to three times per week
Four or more times per week
In the past month, how many drinks containing alcohol did you have on a typical day when you were drinking?
0
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
In the past month, how often did you have 6 or more drinks on one occasion?
Never
Once
Once per week
Daily or almost daily
In the past month, how often have you used marijuana (social or medical)?
Never
Once or twice
Once or twice weekly
Three or five times weekly
Daily or almost daily
In the past month, how often have you used the following substances: crack/cocaine, amphetamines that are not prescribed to you, ecstasy, heroin, opioids not prescribed to you, or any other recreational drugs not previously mentioned?
Never
Once or twice
Once or twice weekly
Daily or almost daily
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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BCFS00532
