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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
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
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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 65 years of age or older?
Yes
No
BMI question
Standard
Height
Weight
Have you begun having cognitive difficulties (ex. memory loss, frequently asking the same question or repeating the same story over and over, not recognizing familiar people and places) in the past 5 years?
Yes
No
Do you fast for more than 12 hours a day?
Yes
No
Are you actively participating in a formal weight loss program or significantly restricting your calorie intake?
Yes
No
Have you experienced unstable angina, heart attack, or stroke within the past 3 months?
Yes
No
Do you require continuous supplemental oxygen to manage a chronic pulmonary condition or heart failure?
Yes
No
Do you have a diagnosis of rheumatoid arthritis, Parkinson's disease, or are you currently on dialysis?
Yes
No
Have you received active cancer treatment in the past year?
Yes
No
Are you currently taking insulin or an insulin-mimicking medication?
Yes
No
Do you have a known history of skin sensitivity or allergic reaction to adhesives?
Yes
No
Are you currently taking medications that require you to eat within 16 hours of taking them?
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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Tagged
BCFS00646
