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Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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First Name
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Gender
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Date of Birth
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What city do you live in?
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What state do you live in?
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Select all of the following that 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
Which of the following psychiatric conditions have you been diagnosed with?
Depression
Anxiety
Bipolar disorder
Schizophrenia or related condition
OCD
PTSD
Borderline personality disorder
Antisocial personality disorder
Other
None of the above
Have you experienced your first episode of psychotic illness within the last three years?
Yes
No
Were you intoxicated with alcohol during your first episode?
Yes
No
Which of the following substance use disorders have you been diagnosed with?
Alcohol use disorder
Opioid use disorder
Cocaine use disorder
Meth use disorder
Cannabis use disorder
Sedative, hypnotic, or anxiolytic use disorder
Hallucinogen use disorder
Inhalant use disorder
Tobacco use disorder
Other
None of the above
In the past 6 months, how often have you consumed alcohol?
I do not consume alcohol.
Less than once a month.
Once a month or less.
2-4 times a month.
2-3 times a week.
4 or more times a week.
Which second-generation (atypical) antipsychotic medications are you currently taking?
risperidone (Risperdal)
olanzapine (Zyprexa)
quetiapine (Seroquel)
aripiprazole (Abilify)
clozapine (Clozaril)
Ziprasidone (Geodon)
lurasidone (Latuda)
Paliperidone (Invega)
asenapine (Saphris)
Iloperidone (Fanapt)
Other
None of the above
Please indicate other second-generation (atypical) antipsychotic medications you are taking
Have you had any changes to your medication in the last 3 weeks?
Yes
No
Excluding schizophrenia-related disorders, do you have a history of any other clinically significant diseases or conditions such as epilepsy or significant head injury?
Yes
No
Which of the following statements apply to your pregnancy status or experience?
Not pregnant/Not applicable
Currently pregnant
Planning to become pregnant in the near future
Recently gave birth
Currently breastfeeding
Do you have any limitations that would prevent you from safely undergoing an MRI scan, such as having non-removable metal objects in your body (implants, pacemakers, etc.) or experiencing claustrophobia?
Yes
No
Would you be willing to abstain from taking sedatives or anxiolytics on the day of the study assessment? This includes medications that are typically used to induce sedation or reduce anxiety.
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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