BCFS00613-UCLA-Grodin-AUD [Screening Form] -

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?

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

What is your sex assigned at birth?

Male

Female

Using the picture below as a reference, how many alcoholic drinks do you usually have per week?

None

1-2 drinks

3-5 drinks

6-9 drinks

10-14 drinks

More than 14 drinks

Using the picture below as a reference, how many alcoholic drinks do you usually have per week ?

None

1-2 drinks

3-4 drinks

5-7 drinks

More than 7 drinks

Image:

Has a clinical professional ever told you that you have a psychiatric problem such as schizophrenia, bipolar disorder, manic-depression, psychotic disorder, or any other psychiatric disorder?

Yes

Has a clinical professional ever told you that you have diabetes, obesity, inflammatory bowel disease, or any other inflammatory diseases?

Yes

Have you been diagnosed with any of the following conditions: chronic obstructive pulmonary disease, chronic kidney disease, Type 2 diabetes, inflammatory bowel disease, sickle-cell disease, any serious heart conditions (heart failure, coronary artery disease, etc.), or immunocompromised state (i.e. weakened immune system) from solid organ transplant?

Yes

Do you currently use non-prescription drugs (select all that apply):

Methamphetamine

Marijuana

Cocaine

Morphine

Heroin

Prescription drugs for recreational purposes

None of the above

Are you pregnant, nursing, or planning to get pregnant in the next 4 months (females only)?

Yes

N/A

Have you ever had surgery involving implants or replacements (e.g. aneurysm surgery, heart valve replacement, brain clips, joint replacements, intracranial bypass, or any other surgery?

Yes

Please select which of the following apply to you:

Prosthetic devices such as a cardiac pacemaker or insulin pump

Metal in your body or mouth such as braces, permanent retainers, metal plates

Tattoos, permanent eyeliner, permanent artificial eyebrows

Suffer from Claustrophobia

Sheet metal worker or welder

None of the above

If applicable, were your tattoos, permanent eyeliner, or permanent artificial eyebrows done in professional ink?

Yes

N/A

Do you currently use or have you used antibiotics or probiotics in the past 3 months?

Yes

Have you had a head injury or prolonged period of unconsciousness (30 minutes)?

Yes

What day of the week AND/OR time of day works best for us to contact you by phone?

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