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
Male
Female
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Date of Birth
Can you receive text messages at this phone number?
Yes
No
How old are you (in years)?
BMI question
Standard
Height
Weight
Have you ever been diagnosed with either type 1 or type 2 Diabetes?
Yes
No
Have you ever been diagnosed with a psychiatric condition (e.g. depression, bipolar disorder, anxiety, ADHD, eating disorder)?
Yes
No
When I'm around fattening food I love, it's hard to stop myself from at least tasting it.
Don't agree at all
Agree a little bit
Agree somewhat
Agree
Strongly Agree
It seems like I have food on my mind a lot.
Don't agree at all
Agree a little bit
Agree somewhat
Agree
Strongly Agree
I feel out of control in the presence of delicious food.
Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree
When it comes to foods I love, I have no will power.
Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree
I can't stop thinking about eating no matter how hard I try
Never/not applicable
Rarely
Sometimes
Often
Usually
Always
If I am craving something, thoughts of eating it consume me.
Never/not applicable
Rarely
Sometimes
Often
Usually
Always
Would you like UC San Diego Center for Healthy Eating and Activity Research (the group conducting this study) to keep your name and contact information in our database to re-contact you for future studies?
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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