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HIC# 2000023970
Screening Form
Please complete the screening form below
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First Name
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Last Name
Phone Number
Email Address
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Gender
Male
Female
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Date of Birth
Are you between 21-70 years old?
Yes
No
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
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Maine
Maryland
Massachusetts
Michigan
Minnesota
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New York
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Are you able to read and write English?
Yes
No
How many alcoholic drinks do you typically consume in a week?
Select
None
1-2 drinks
3-4 drinks
5-7 drinks
More than 7 drinks
Are you able to take oral medications and commit to following the prescribed medication regimen for the study?
Yes
No
Are you willing to cut down on drinking during the treatment period of this study?
Yes
No
Can you make reasonable transportation arrangements to the study site in New Haven, Connecticut?
Yes
No
Are you currently pregnant or nursing?
Yes
No
N/A - I am not a female
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?
None of the above
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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BCFS00589
