Skip to content
Screening Form
Please complete the screening form below
Displayed
First Name
Displayed
Last Name
Phone Number
Email Address
Hidden
Gender
Male
Female
Displayed
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 between the ages of 18 and 65?
Yes
No
Are you able to read and complete forms in English?
Yes
No
Are you currently in treatment for OUD and receiving buprenorphine-naloxone sublingual film, sublocade injection, or buprenorphine sublingual tablet?
Yes
No
What is your buprenorphine dosage?
Are you currently pregnant or lactating?
Yes
No
N/A- I am not a female
Do you currently take any antidepressant medications (tricyclic antidepressants, SSRIs, SNRIs, MAOIs), antibiotic linezolid, antiepileptics, or CNS stimulants (amphetamine, methylphenidate)?
Yes
No
Do you have any history of an adverse reaction or allergy to dextromethorphan or bupropion?
Yes
No
Have you been diagnosed with a substance use disorder other than opioids, cocaine, marijuana, nicotine, or mild to moderate alcohol use disorder?
Yes
No
When was the last time you used benzodiazepine?
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.
Displayed
Captcha
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00719
