Skip to content
Screening Form
Please complete the screening form below
Displayed
First Name
Displayed
Last Name
Phone Number
Email Address
Hidden
Gender
Male
Female
Hidden
Date of Birth
Child First Name
Child Last Name
Child Date of Birth
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 is your child's sex assigned at birth?
Male
Female
Intersex
What is your child's gender identity?
Male
Female
Non-binary
Other
Please answer the below question about your child.
BMI question
Standard
Height
Weight
Has your child ever been diagnosed with autism?
Yes
No
Can we leave messages on or text the phone number you provided above?
Yes
No
Would you like to be contacted for future studies?
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.
Displayed
Captcha
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00611
