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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
Alaska
Arizona
Arkansas
California
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Delaware
Florida
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Hawaii
Idaho
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Indiana
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Maryland
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New Hampshire
New Jersey
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New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
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 30 and 70?
Yes
No
Do you have a history of symptomatic COVID-19 within the past 12 months?
Yes
No
Do you continue to experience lingering long-term COVID-19 symptoms, regardless of the time that has passed since your initial infection?
Yes
No
N/A- I did not have symptomatic COVID-19
Do you currently have an active COVID-19 infection?
Yes
No
Are you currently pregnant?
Yes
No
N/A - I am not a female
Please select any of the following conditions that currently apply to you:
HIV
Cardiovascular Disease
Cancer (other than skin cancer)
Diabetes
End stage renal, liver, or lung disease
Anemia
None of the above
In the last 30 days, have you been hospitalized for more than 24 hours?
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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BCFS00639
