Skip to content
Screening Form
Please complete the screening form below.
First Name
Hide on Form
Last Name
Hide on Form
Phone Number
Email Address
Gender
Show on Form
Male
Female
Date of Birth
Hide on Form
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
Are you currently receiving care at a Ryan White Clinic in South Carolina?
Yes
No
Are you HIV positive?
Yes
No
Unsure
Please select which of the following options best applies to your HIV care:
Select
I have been diagnosed with HIV in the past 3 months
I have missed some days of taking my ART (antiretroviral therapy) in the past 12 months
I have missed one or more of my healthcare sessions for my HIV treatment in the past 12 months
My viral load has been detectable in the past 12 months
None of the above
N/A-I am not HIV-positive
Are you fluent in English?
Yes
No
Have you been diagnosed with any significant cognitive impairment (for example, dementia or traumatic brain injury) or a developmental disability (for example, autism)?
Yes
No
Do you currently experience any unusual thoughts, hallucinations, or difficulty distinguishing between what is real and what is not?
Yes
No
Have you had any changes in medication for mental health (antidepressants, antianxiety, etc) within the past 4 weeks?
Yes
No
Have you ever experienced a particularly horrible, frightening, or traumatic event?
Yes
No
In the past month have you had nightmares about the event(s) or thought about the event(s) when you did not want to?
Yes
No
In the past month have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
Yes
No
In the past month have you been constantly on guard, watchful, or easily startled?
Yes
No
In the past month have you felt numb or detached from people, activities, or your surroundings?
Yes
No
In the past month have you felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
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.
Captcha
Hide on Form
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00555
