Cannabis Withdrawal Research Study – Screening Questionnaire

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1990)

City and State You Live In

Do you consent to be contacted about future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Height (in inches):

Height and weight are used to compute BMI; eligibility requires BMI between 18.0 and 38.0.

Approximate weight (in pounds):

Are you a heavy, daily cannabis user?

Yes No

Are you interested in stopping cannabis use and reducing withdrawal symptoms?

Yes No

Do you currently use cannabis multiple times per day, at least 6 days per week?

Yes No

Have you been using cannabis this frequently for at least 6 months?

Yes No

Approximately how much cannabis do you use daily?

Less than 1.5 grams/day 1.5 grams/day or more Equivalent amount in edibles/vapes/concentrates

Did you use cannabis during the screening period, and are you willing to continue use until the day before study admission?

Yes No

When you have tried to stop or reduce cannabis in the past year, did you experience cravings and at least 3 withdrawal symptoms?

Yes No

Which withdrawal symptoms have you experienced? (Select all that apply)

Irritability Anxiety/nervousness Sleep problems Decreased appetite Restlessness Depressed mood Physical symptoms (headache, nausea, chills, stomach pain, sweating) Strong cravings for cannabis

Eligibility requires strong cravings plus at least 3 other withdrawal symptoms.

Are you willing to stop using cannabis, CBD products, hemp products, delta-8/delta-10 products, THC-A products, and similar cannabinoid products after enrollment and throughout the study?

Yes No

Are you willing to stay overnight in an inpatient clinic for Days 1–6 of the study?

Yes No

Are you willing to attend weekly outpatient clinic visits and daily evening video calls?

Yes No

Do you have regular internet access and video call capability?

Yes No

Are you able to take capsules and follow a medication schedule at approximately the same time daily?

Yes No

Are you willing to avoid alcohol during the entire study?

Yes No

Do you currently use nicotine products?

Yes No

Are you willing to maintain your current nicotine use during the study without attempting to quit?

Yes No

Are you able to read, understand, and complete daily questionnaires and diaries?

Yes No

Have you ever been diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder?

Yes No

Do you currently have an unstable psychiatric condition that may require medication changes or therapy changes during the study?

Yes No

In the past 2 years, have you had a substance use disorder involving drugs other than cannabis, nicotine, or caffeine?

Yes No

Do you regularly or frequently consume alcohol and feel unable to stop during the study?

Yes No

Have you been a heavy alcohol user in the past year?

Yes No

More than 2 drinks/day for men or more than 1 drink/day for women.

Have you binge drank alcohol within the past 30 days?

Yes No

5 or more drinks for men, or 4 or more drinks for women, on one occasion.

Are you currently using cannabis for a physician-directed medical condition such as epilepsy?

Yes No

Do you have any of the following unstable medical conditions? (Select all that apply)

Cancer Heart disease Pulmonary hypertension Type 1 diabetes Uncontrolled Type 2 diabetes HIV/AIDS Significant liver or kidney disease Other serious medical condition None of the above

Have you recently had suicidal thoughts, violent behavior, homicidal thoughts, or suicide attempts within the past year?

Yes No

Have you ever had an allergic reaction or intolerance to any of the following? (Select all that apply)

Nabilone Gabapentin Pregabalin None of the above

Are you currently using any of the following? (Select all that apply)

Have you used gabapentin or pregabalin within the past 30 days?

Yes No

Have you used an investigational drug or biologic within the past 30 days?

Yes No

Do you currently have suspected active COVID-19 or influenza infection?

Yes No

Are you planning to receive any vaccination, including COVID-19 vaccination, during the study?

Yes No

Have you received a vaccination within the past 5 days?

Yes No

What is your sex at birth?

Male Female

Are you currently pregnant or breastfeeding?

Yes No

If you are able to become pregnant, are you willing to use an approved method of birth control during the study and for 30 days afterward?

Yes No Not applicable

If you are sexually active, are you willing to use barrier contraception and avoid sperm donation during the study and for 90 days after the last dose?

Yes No Not applicable