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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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Age
Sex assigned at birth:
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Intersex
Race
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Black/African American
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Ethnicity
Hispanic/Latino
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BMI question
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Height
Weight
Do you use any tobacco products?
Tobacco/Cigarettes
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Chewing tobacco
Other
None
Please specify:
Are you currently pregnant or nursing?
Yes
No
Have you ever been diagnosed with a mental health condition?
Yes
No
Which condition(s)?
What medications are you currently taking?
Have you experienced significant head trauma in your life?
Yes
No
Please describe:
Do you have any neurological conditions like strokes, seizures, or migraine headaches?
Yes
No
Please describe:
Do you have any metal in your body (pacemaker, surgical plates/pins, other medical implants, etc.)?
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No
Please describe:
Are you ok with having your blood drawn?
Yes
No
Are you ok with having a urine drug screen?
Yes
No
Are you ok with sitting very still in an MRI machine?
Yes
No
Are you ok with sitting very still in a PET machine?
Yes
No
Are you currently enrolled in any research studies involving medication or medical devices?
Yes
No
Have you participated in any research studies involving medication or medical devices in the past 30 days?
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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BCFS00697
