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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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What was your sex assigned at birth?
Male
Female
Other
Prefer not to answer
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Date of Birth
What city do you live in?
What state do you currently live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Washington DC
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
In the past week, how intense has your back pain been on a scale of 0-10 (with 0 = no pain and 10 = pain as bad as you can imagine)?
0
1
2
3
4
5
6
7
8
9
10
How long has back pain been an issue for you?
Less than 1 month
1-3 months
3-6 months
6-12 months
More than 1 year
In the last 3 months, how often has your back pain bothered you?
Barely any days
Less than half the days
Half the days
More than half the days
Every day
Do you experience leg pain?
Yes
No
Is your leg pain worse than your back pain?
Yes
No
Have you had back surgery in the last 2 years?
Yes
No
Are you currently involved in any lawsuits related to your pain?
Yes
No
Are you currently applying for any disability payments related to your pain?
Yes
No
Do you plan to be involved in any lawsuits or apply for any disability payments related to your pain in the next 6 months?
Yes
No
Have you received a legal settlement or other disability payments related to your pain over the past 2 years?
Yes
No
Please select any of the following conditions that apply to you:
Serious medical illness (e.g., current or recent cancer diagnosis, severe cardiovascular disease)
Recent unexplained, unintended weight loss of 20 lbs or more
Recent vertebral fracture, known spinal fractures, or tumors
Known sensory/motor abnormalities in the trunk or legs
Difficulty controlling bowel function
Rheumatoid arthritis, polymyalgia rheumatica, scleroderma, lupus, or polymyositis
None of the above
Do you have a recent history of suicide attempts or self-harm behaviors within the past 5 years (including non-suicidal self-harm)?
Yes
No
Have you been hospitalized for psychiatric reasons as an inpatient in the past 5 years?
Yes
No
Do you currently experience active psychosis or mania?
Yes
No
Do you currently have active substance abuse issues or a history of substance abuse within the past 2 years?
Yes
No
Do you have a major surgery or other major medical event planned in the coming six months?
Yes
No
Will you have reliably suitable conditions for telehealth appointments over the next two months, including a computer or tablet, reliable fast internet, and a quiet comfortable room that is reliably available?
Yes
No
Do you have any major and interfering changes in employment or housing anticipated over the next six months?
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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BCFS00685
