BuildClinical | Customer Preview

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

Displayed

First Name

Displayed

Last Name

Phone Number

Email Address

Displayed

Date of Birth

Displayed

What city do you live in?

Displayed

What state do you live in?

Name of participant (the person you care for)

Participant's Date of Birth

Displayed

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 category best describes the participant?

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

Has the person you care for been diagnosed with Autism Spectrum Disorder by a trained professional?

Yes

Do you live with or spend at least 4 hours per day with the participant?

Yes

Is the participant comfortable swallowing medication in pill form?

Yes

Does the participant have a severe or unstable psychiatric condition (e.g., schizophrenia or other psychotic disorder, bipolar disorder, major depressive disorder)?

Yes

Has the participant had any substance abuse disorders in the past 6 months?

Yes

Does the participant have any known allergies, hypersensitivity, or intolerance to Pimavanserin?

Yes

What is the participant's weight in pounds? What is the participant's height in feet and inches?

BMI question

Standard

Height

Weight

Does the participant have a history of long QT syndrome or a family history of sudden death?

Yes

Has the participant had a seizure within the past 12 months?

Yes

Is the participant pregnant or breast-feeding, or planning to become pregnant or breastfeed while participating in the 3 month duration of the study?

Yes

Does the participant currently or have a history within the previous 3 months of a serious and/or unstable neurologic, cardiovascular, respiratory, gastrointestinal, renal, hepatic, hematologic, or other medical disorder?

Yes

You agree that BuildClinical may provide your personal information to third parties for the purpose of determining whether you are eligible for clinical study participation. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.

Displayed

Captcha

Customer Preview

Screening Form

Displayed

Displayed

Hidden

Displayed

Displayed

Displayed

Displayed

Displayed

Eligibility Criteria:

The eligibility criteria listed here is only visible in the Customer Preview version of the form. Eligibility will not be visible for potential participants filling out the form.