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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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Are you between the ages of 40-75?
Yes
No
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
Other
If you selected ‘Other’ in the previous question, please specify
Have you been diagnosed with Rheumatoid Arthritis (RA)?
Yes
No
Are you currently taking or prescribed any of the following medications?
Methotrexate (MTX) or Amethopterin / Rheumatrex or Trexall
Sulfasalazine (SSZ)/Salazopyrin or Azulfidine
Hydroxochloroquine (HCQ)/ Plaquenil
Leflunomide (LEF)/ Arava
Adalimumab/ Humira, Amgevita
Etanercept/ Enbrel
Certolizumab pegol/ Cimzia
Golimumab/ Simponi
Infliximab/ Remicade, Inflectra
Abatacept/ Orencia
Tocilizumab (TCZ)/ Actemra
Sarilumab/ Kevzara
Tofacitinib/ Xeljanz
Baricitinib/ Olumiant
Upadacitinib/ Rinvoq
Rituximab/ Rituxan, Truxima
I am taking more than 1 of the above medications
None of the above
Please specify what medications you are currently taking:
Do you speak English?
Yes
No
Do you reside/live in the United States?
Yes
No
Do you have reliable internet access?
Yes
No
Are you taking any medications that are intended to lower your cholesterol (statin)?
Yes
No
Have you had a cholesterol test in the past 2 years that you have discussed with your physician?
Yes
No
Do you have a known history of diabetes?
Yes
No
Do you have a known history of cardiovascular disease (open heart surgery, coronary angioplasty, heart failure, heart attack, stroke)?
Yes
No
What is the best time for a research team member to contact you about this study?
Morning (before 12:00pm)
Afternoon (between 12:00pm - 5:00pm)
Evening (after 5:00pm)
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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BCFS00533
