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

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

Other

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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

What sex were you assigned at birth?

Male

Female

Intersex

How many alcoholic beverages do you typically consume per week?

How many alcoholic drinks do you typically consume per week?

Has anyone ever told you that you have a psychotic disorder? (e.g., schizophrenia, bipolar disorder)

Yes

No

Do you regularly use any of the following non-prescription drugs for recreational purposes? (e.g., cocaine, methamphetamine, ecstasy, heroin, opioids, LCD, mushrooms, benzodiazepines)

Yes

No

Which of the following statements apply to your pregnancy status or experience?

Not pregnant/Not applicable

Currently pregnant

Recently gave birth

Currently breastfeeding

Planning to become pregnant in the near future

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

Yes

No

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

No

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

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

Yes

No

N/A

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

Yes

No

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

Yes

No

What day(s) of the week are the best to contact you by phone?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What is the best time of day to contact you?

Early Morning (8AM-10AM)

Late Morning (10AM-12PM)

Early Afternoon (12PM-3PM)

Late Afternoon (3PM-5PM)

Evening (5PM-7PM)

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