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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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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
On average, how many cigarettes do you smoke each day?
None
1-2 cigarettes
3-7 cigarettes
8-12 cigarettes
13-20 cigarettes
More than 20 cigarettes
Are you motivated to quit smoking within the next 30 days?
Yes
No
Can you speak, read, and write English?
Yes
No
For your safety, we ask that you not engage in study procedures (like completing surveys on your phone or visits with the staff) while operating a vehicle or machinery. Do you agree to this requirement?
Yes
No
Do you have skin allergies or chronic skin diseases that may interfere with usage of the nicotine patch?
Yes
No
Do you have a pacemaker or implanted cardiac device?
Yes
No
Are you currently in a smoking cessation program?
Yes
No
Were you in a smoking cessation program in the past 90 days?
Yes
No
Do you currently chew nicotine gum, use the nicotine patch, nicotine spray, nicotine inhaler, or nicotine lozenges, or do you currently take medication or other aids intended for tobacco cessation (e.g., Wellbutrin or Zyban [bupropion], Chantix [varenicline])?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Have you ever had an overactive thyroid, type 1 diabetes, or tumors in your adrenal gland?
Yes
No
Have you ever had a heart attack, angina, cardiac arrhythmia, or a blood circulation problem?
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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BCFS00580
