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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 female?
Yes
No
Are you right-handed?
Yes
No
Do you have any history of neurological disorders or disease, for example, stroke or seizures? Do you have any history of recurrent fainting spells (unrelated to eating behaviors) or vertigo?
Yes
No
Unsure
Have you ever eaten in one sitting what most people would consider an unusually large amount of food and experienced a sense of loss of control, like it was hard to stop once you started?
Yes
No
Have you had episodes like this at least once per week on average over the last 3 months?
Yes
No
Have you ever made yourself vomit to control your shape or weight or compensate for an episode of loss of control eating?
Yes
No
Has this been in the last 6 months?
Yes
No
Have you ever done anything else to compensate for food you've eaten or to control your shape or weight? This might include things like taking laxatives or diuretics, taking diet pills, intense and compulsive exercise, or fasting.
Yes
No
If we added up all of the times you [as applicable, self-induced vomiting, took laxatives or diuretics, took diet pills, compulsively exercised, fasted] per week in the last 3 months, have you had these behaviors at least once per week on average over the last 3 months?
Yes
No
Are you able to attend 2 phone interviews and 3 in-person research visits in Manhattan, New York?
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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Tagged
BCFS00562
