Skip to content
Apply Now
Screening Form
Please complete the screening form below
First Name
Hide on Form
Last Name
Hide on Form
Phone Number
Email Address
Gender
Show on Form
Male
Female
Date of Birth
Hide on Form
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
Check all the categories that best describe 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
What is your gender?
Male
Female
Other
Are you between the ages of 18 and 40?
Yes
No
BMI question
Standard
Height
Weight
Do you have normal or corrected-to-normal (with the help of glasses or contacts) vision?
Yes
No
What is your dominant hand?
Right
Left
Ambidextrous
Are there times when you eat a very large amount of food in a short period of time?
Yes
No
Please select all of the following you experience during these episodes:
Eat much more rapidly than normal
Eat until you feel uncomfortably full
Eat large amounts of food when you’re not physically hungry
Eat alone because of feeling embarrassed by how much you are eating
Feel disgusted with yourself, depressed, or very guilty afterwards
On average, over the past 3 months, how often have you had these episodes?
Daily
A few times a week
Once a week
A few times a month
Rarely
Never
Are these episodes often accompanied with compensatory behaviors such as vomiting, excessive exercise, or fasting?
Yes
No
Do these episodes occur exclusively during episodes of anorexia nervosa, bulimia nervosa, or avoidant/restrictive food intake disorder?
Yes
No
Do you have extreme dietary limitations (e.g., veganism) or pervasive food allergies that would substantially restrict the range of foods you can consume?
Yes
No
Are you pregnant, currently breastfeeding, or seeking to become pregnant in the next 3 months?
Yes
No
N/A- I am not a female
Do you have any limitations that would prevent you from safely undergoing an MRI scan, such as having non-removable metal objects in your body or experiencing claustrophobia?
Yes
No
Do you have a serious or unstable medical disease, such as autoimmune, cardiovascular, hepatic, renal, respiratory, endocrine, neurologic, or hematologic disease?
Yes
No
Have you experienced recent thoughts of suicide or made a suicide attempt in the last 12 months?
Yes
No
Have you been diagnosed with a psychotic disorder (e.g., schizophrenia, psychosis)
Yes
No
Do you currently have difficulty abstaining from smoking nicotine for 12+ hours or marijuana for 48+ hours?
Yes
No
Have you ever had a major neurocognitive disorder, neurological issue (like stroke or seizure disorder), moderate to severe head injury, or brain procedure (such as ECT or deep brain stimulation) in your medical history?
Yes
No
Have you ever been diagnosed with intellectual disability, autism spectrum disorder, or a severe communication, learning, or motor disorder?
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.
Captcha
Hide on Form
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00724
