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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
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Female
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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
What is your gender?
Male
Female
Other
Which of the following apply to you?
I am not pregnant/I’m not female
I am pregnant
I am breastfeeding
I am planning to become pregnant in the near future
Which of the following neurological conditions have you been diagnosed with?
Alzheimer's disease
Parkinson's disease
Epilepsy
Multiple sclerosis
Cerebral palsy
Down syndrome
Huntington's disease
Migraine
Amyotrophic lateral sclerosis (ALS)
None of the above
Have you actively experienced any of the following substance use disorders in the past 3 months?
Alcohol use disorder
Opioid use disorder
Cocaine use disorder
Stimulant use disorder
Cannabis use disorder
Other substance use disorder
None of the above
Have you had a significant head injury or loss of consciousness that lasted more than 30 minutes?
Yes
No
Which of the following best applies to you?
Experience symptoms of schizophrenia but have not been diagnosed
Diagnosed with schizophrenia or related condition
None of the above
Do you ever experience hearing voices, sounds, or noises that others around you cannot hear?
Yes
No
Have you undergone Electroconvulsive Therapy (ECT) or Transcranial Magnetic Stimulation (TMS) treatment within the last 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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BCFS00788
