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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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Please provide your street address, city, state, and zip code.
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
Have you used cocaine in the last 7 days?
Yes
No
Have you taken any cocaine treatment-related medications within the past 6 months?
Yes
No
Have you been legally required by a court to undergo treatment for issues related to cocaine?
Yes
No
Do you have a dependence on psychoactive substances other than cocaine, nicotine, or marijuana (i.e., alcohol, heroin, methamphetamine, ecstasy)?
Yes
No
Do you have a psychiatric disorder (i.e., bipolar, depression, OCD) that requires treatment?
Yes
No
Do you have a history of head injury, seizures, neurologic disorders including cerebrovascular disease, multiple sclerosis, neurodegenerative diseases, or other major medical illness?
Yes
No
Do you have any significant medical conditions that require medical intervention or close supervision due to their severity or impact on your health?
Yes
No
Are you able to abstain from cocaine use at key points during the study?
Yes
No
Are you willing and able to comply with scheduled visits and study procedures?
Yes
No
Are you able to lie on your back for up to 1 hour for multiple imaging tests?
Yes
No
Are you expected to have a stable residence for the next two months?
Yes
No
Do you have any metal in your body that cannot be removed, claustrophobia, anxiety, or other conditions that would prevent you from undergoing an MRI?
Yes
No
Do you have a cardiac pacemaker, cardioverter defibrillator, or neurostimulator present in your body?
Yes
No
Are you pregnant or planning to get pregnant in the next 2 months?
Yes
No
N/A- I am not a female
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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BCFS00579
