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HIC# 2000026630
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?
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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 was your average daily cigarette consumption over the past year?
None
1-5 cigarettes per day
6-9 cigarettes per day
10-15 cigarettes per day
16 or more cigarettes per day
Are you able to orally take medications and willing to follow the prescribed medication regimen for this study?
Yes
No
Have you been prescribed or taken any of the following prescription or over the counter medications within the past 6 months?
Anti-Depressants
Benzodiazepines
Stimulants
Sedatives
Opiates
Anti-Psychotics
Blood Pressure Medications
Sleep Medications
Vitamins
Over the counter pain medications
Any other medications not listed?
Can you make reasonable transportation arrangements to the study site in New Haven, Connecticut?
Yes
No
Do you have any plans to move within the next 3 months?
Yes
No
Are you currently pregnant or nursing?
Yes
No
Are you the sole individual in your household completing this screener? Please be aware that only one member per household is allowed to participate in this 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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Tagged
BCFS00575
