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

Hidden

Gender

Male

Female

Other

Displayed

Date of Birth

Displayed

What city do you live in?

Displayed

What state do you live in?

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

Have you been diagnosed with Autism Spectrum Disorder by a trained professional?

Yes

Do you live with a parent, primary caregiver, or other adult informant who can complete study measures on the basis of spending an average of at least 4 hours per day with you?

Yes

Are you comfortable swallowing medication in pill form?

Yes

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

Yes

Have you had any substance abuse disorders in the past 6 months?

Yes

Do you have any known allergies, hypersensitivity, or intolerance to Pimavanserin?

Yes

BMI question

Standard

Height

Weight

Do you have a history of long QT syndrome or a family history of sudden death?

Yes

Have you had a seizure within the past 12 months?

Yes

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

Yes

Do you currently or do you 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

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.

If ALL of these conditions are TRUE: