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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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Gender
Male
Female
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Date of Birth
What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
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 18 or older?
Yes
No
Is this your first baby?
Yes
No
How long ago did you have your first baby?
Less than 2 months ago
Between 2 and 7 months ago
More than 7 months ago
How many weeks ago did you have your first baby?
Less than 1 week ago
1 week ago
2 weeks ago
3 weeks ago
4 weeks ago
5 weeks ago
6 weeks ago
7 weeks ago
Do you plan on becoming pregnant in the next 16 to 18 weeks?
Yes
No
BMI question
Standard
Height
Weight
Do you currently perform 150 minutes per week of moderate to vigorous intensity physical activity? (Moderate-intensity activities should increase your heart rate to a point that you can talk but not sing.)
Yes
No
Do you go to bed and get out of bed at the same time or within one hour every day rarely, sometimes, or usually?
Rarely
Sometimes
Usually
Are you satisfied with your sleep rarely, sometimes, or usually?
Rarely
Sometimes
Usually
Do you stay awake all day without dozing rarely, sometimes, or usually?
Rarely
Sometimes
Usually
Are you asleep or in bed between 2 and 4 a.m. rarely, sometimes, or usually?
Rarely
Sometimes
Usually
Do you spend less than 30 minutes awake at night rarely, sometimes, or usually? This includes the time it takes to fall asleep and the time you spend awake after initially falling asleep.
Rarely
Sometimes
Usually
Do you have a smartphone and home Internet access?
Yes
No
Are you willing to be randomly assigned to receive the education brochures or online intervention?
Yes
No
Are you participating in another weight loss program?
Yes
No
Please list any medications you are taking
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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BCFS00713
