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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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Date of Birth
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What city do you live in?
What state do you live in?
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Alabama
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Arizona
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Delaware
Florida
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Hawaii
Idaho
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
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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
Are you between the ages of 45 and 95?
Yes
No
Do you currently experience pain in either one or both of your knees?
Yes
No
Do you have an active symptomatic systemic rheumatic disease/condition (e.g., rheumatoid arthritis, systemic lupus erythematosus), or fibromyalgia, that causes pain in areas other than the knee(s) that is equal to or more severe than the pain in your knee(s)?
Yes
No
Do you experience chronic pain that is more severe in any other part of your body apart from the knee?
Yes
No
Have you had a significant surgical procedure performed on your affected knee(s)?
Yes
No
Do you use opioids daily?
Yes
No
Do you have uncontrolled hypertension or an unstable cardiovascular or peripheral arterial disease?
Yes
No
Have you ever been diagnosed with a neurological disease (e.g., Parkinson's, multiple sclerosis, epilepsy), or do you have any evidence of a previous brain injury, such as stroke or traumatic brain injury?
Yes
No
Have you had a serious psychiatric disorder within the last 12 months either required hospitalization or is characterized by active suicidal thoughts?
Yes
No
Do you currently have a substance use disorder or a history of being hospitalized for the treatment of a substance use disorder?
Yes
No
Do you have any cognitive impairments that could hinder your understanding of the study procedures?
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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BCFS00590
