Today's Date
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Today M-D-Y
Before booking your first appointment, you will need to be associated with the research study on the Partners Electronic Medical Records Database. During this process we will gain access to a summary of your past medical record within Partners. Do you give your consent for this to occur?
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Yes
No
Male
Female
Do you have a Social Security Number?
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Yes
No
This is for study payment purposes.
Where did you hear about the study?
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Craigslist BWH Website Partners Clinical Trials Site Harvard DSM Site Other
Any personal or identifying information asked during this screen will need to be stored in the Division of Sleep Medicine Database regardless of your eligibility for the study. Do you give us your permission to enter information in our Database?
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Yes
No
If you are found ineligible, or are otherwise uninterested in this particular study, would you like to be informed about other studies in the future?
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Yes
No
Phone Number
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State
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Do you have an emergency contact?
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Yes
No
Current Occupation
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Employed Unemployed Student
Date of Birth
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Today M-D-Y
Inches
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Weight
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Lbs.
Handedness
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Right
Left
Have you ever participated in a Research Study before?
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Yes
No
Was it a BWH Sleep Study?
Yes
No
Month, Year
What type of study did you participate in? Please explain.
Yes
No
Was it a BWH Sleep Study?
Yes
No
Month, Year
What type of study did you participate in? Please explain.
Yes
No
Was it a BWH Sleep Study?
Yes
No
Month, Year
What type of study did you participate in? Please explain.
Yes
No
Do you currently smoke cigarettes?
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Yes
No
1 2 3 4 5 6 7 8+
Do you currently use any chewing tobacco, cigars, or nicotine patches?
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Yes
No
Do you have any problems with sleep?
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Yes
No
Typical Bedtime
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Before 8:00pm 8:00pm 8:15pm 8:30pm 8:45pm 9:00pm 9:15pm 9:30pm 9:45pm 10:00pm 10:15pm 10:30pm 10:45pm 11:00pm 11:15pm 11:30pm 11:45pm 12:00am 12:15am 12:30am 12:45am 1:00am 1:15am 1:30am 1:45am 2:00am 2:15am 2:30am 2:45am 3:00am After 3:00am
Typical Waketime
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Before 5:00am 5:00am 5:15am 5:30am 5:45am 6:00am 6:15am 6:30am 6:45am 7:00am 7:15am 7:30am 7:45am 8:00am 8:15am 8:30am 8:45am 9:00am 9:15am 9:30am 9:45am 10:00am 10:15am 10:30am 10:45am 11:00am 11:15am 11:30am 11:45am 12:00pm After 12:00pm
Typical Bedtime
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Before 8:00pm 8:00pm 8:15pm 8:30pm 8:45pm 9:00pm 9:15pm 9:30pm 9:45pm 10:00pm 10:15pm 10:30pm 10:45pm 11:00pm 11:15pm 11:30pm 11:45pm 12:00am 12:15am 12:30am 12:45am 1:00am 1:15am 1:30am 1:45am 2:00am 2:15am 2:30am 2:45am 3:00am After 3:00am
Typical Waketime
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Before 5:00am 5:00am 5:15am 5:30am 5:45am 6:00am 6:15am 6:30am 6:45am 7:00am 7:15am 7:30am 7:45am 8:00am 8:15am 8:30am 8:45am 9:00am 9:15am 9:30am 9:45am 10:00am 10:15am 10:30am 10:45am 11:00am 11:15am 11:30am 11:45am 12:00pm After 12:00pm
Would you be able to keep a regular 8-hour sleeping schedule?
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Yes
No
When is the last time you stayed up all night (or much later than usual)? How often do you do this?
Do you have any medical illnesses or problems?
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Yes
No
Are you currently using any medications, using inhalers, patches, hormone replacements, or birth control (for women)?
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Yes
No
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Oral
Topical
How long ago did you take it?
Have you traveled outside of the Eastern Time Zone within the past 3 months?
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Yes
No
City, State -or- City, Country
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City, State -or- City, Country
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City, State -or- City, Country
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Do you have any plans to travel in the next few months?
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Yes
No
Have you ever worked the night shift (for example, 11pm to 7am)?
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Yes
No
Night shift work is defined as working anytime during the hours of 1:00am and 6:00am. Anything in the last 3 years should be explained in detail.
Today M-D-Y
Are you still working nights?
Yes
No
Today M-D-Y
How many nights per week?
Which of the following do you have?
Heart Disease Heart Murmur Both (Heart Disease & Murmur)
When did you develop the heart murmur? What is the severity?
What sort of Visual or hearing impairment? If you wear glasses or contacts are you able to complete the study without them?
Please explain the eye injury.
What type of surgery? When was the procedure? Were you under anesthesia?
Please indicate what type of anesthesia you were under and when.
Are you still asthmatic? What type of Asthma inhaler do you use?
What sort of psychiatric care have you received? When? Where you diagnosed with anything? Were you given any medications? Please explain:
Which family member(s) have a mental illness or disease? Which illness/disease?
Please explain the accident or head injury.
If you did lose consciousness, for how long?
How many times per week do you typically drink alcohol?
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0 1 2 3 4 5 6 7+
How many drinks per time?
1-2
3-4
5-6
7+
Antihistimines (medications for allergies)
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Never As Needed 1-2x/month Weekly Daily
Sedatives (anti-anxiety agents such as valium)
* must provide value
Never A few times per year Monthly Weekly Daily
Please specify what medication.
Please specify how often.
Yes
No
When was the most recent time?
Today M-D-Y
Aspirin, Tylenol, other pain relievers
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Never As Needed Weekly Daily
Please specify how often.
Antacids
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Never A few times per year Monthly Weekly Daily
How often? Please Explain.
Health Food Supplements/Remedies (melatonin, herbal ecstasy, ginseng)
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Never A few times per year Monthly Weekly Daily
Please specify which supplement or product you take.
How often do you take this supplement?
Yes
No
When was the last time you took the supplement?
Today M-D-Y
When is the most recent time you used Marijuana?
Today M-D-Y
When is the most recent time you used cocaine?
Today M-D-Y
When is the most recent time you used Amphetamines?
Today M-D-Y
What type? If adderall, was it a Rx?
When is the most recent time you used ecstasy?
Today M-D-Y
When is the most recent time you used sleeping pills?
Today M-D-Y
What type of sleeping pills?
Were/are they a prescription?
Yes
No
When is the most recent time you used LSD, mushrooms?
Today M-D-Y
When is the most recent time you used steroids?
Today M-D-Y
Can you stop during and 3 weeks prior to the study?
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Yes
No
This includes all drugs, meds, alcohol, caffeine, nicotine, chocolate, etc...
When was your last menses?
Today M-D-Y
When was your previous menses?
Today M-D-Y Prior to the one listed above.
Do you have a regular menstrual cycle?
Yes
No
Days from the end of one menses to the start of the next.
Have you ever taken birth control?
Yes
No
When was it started? Are you currently taking it? When was is finished?
Yes No Unsure