Does your menstrual cycle affect your response to sleep loss?

First name:

Last name:

Today's Date

Where did you hear about the study?

Sex?

Do you have a Social Security Number?
(This is for study payment purposes; you do not need to provide it at this time).

Any personal or identifying information asked during
this screen will need to be stored in the Division of
Sleep Medicine Database. Do you give us your
permission to enter information in our Database?

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?

If you are found ineligible, or are uninterested in this particular study, would you like to be informed about other studies in the future?

Current Occupation

Occupation

School

Date of Birth

Age

Feet

Inches

Weight (lbs)

Which is your dominant hand?

Are you color blind?

Have you ever done a Research Study before?

What type of study did you participate in? Please explain. Use as much detail possible.

Was any blood drawn?

When was the study?
(month, year)

Add Another Study

What type of study did you participate in?

Was any blood drawn?

When was the study?
(month, year)

Add Another Study

What type of study did you participate in?

Was any blood drawn?

When was the study?
(month, year)

Do you have any medical illnesses or problems?

Please explain.

Are you currently using any medications, inhalers, patches, or hormone replacements, (birth control, for women)?

Type

Started

Finished

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Type

Started

Finished

Add Another

Type

Started

Finished

Did you formerly or do you currently smoke cigarettes, e-cigarettes, or vaporizers?

Which one of the two are you?

When did you quit smoking?

How many per day?

Do you currently use any chewing tobacco, cigars, or nicotine patches?

Have you traveled outside of the Eastern Time Zone within the past 3 months?

Where?

Date Left

Date Returned

Add Another

Where?

Date Left

Date Returned

Do you have any plans to travel in the next few months?

Where?

When?

Have you ever worked or do you currently work the night shift?

Date started

Are you still working nights?

Date Finished

Shift Start Time

Shift End Time

How many nights per week?

Type of work

Which of the following do you have?

When did it develop? What is the severity?

What kind of lung disease?

When did it develop? What is the severity?

What kind of kidney disease?

When did it develop? What is the severity?

What sort of visual or hearing impairment? If you wear glasses or contact lenses, how much are you able to see without them?

Please explain the eye injury.

What kind of stomach or intestine disease?

When did it develop? What is the severity?

What kind of neurological disease?

When did it develop? What is the severity?

What type of surgery? When was the procedure? Were you under anesthesia?

Please indicate what type of anesthesia you were under and when.

What type of thyroid disease?

When did it develop? What is the severity?

When were you diagnosed with high blood pressure? What is the severity?

What type of diabetes do you have? When were you diagnosed with diabetes?

What type of hepatitis do you have? When were you diagnosed with this?

Which types of hepatitis are you vaccinated for? When did you get your vaccination(s)?

Are you still asthmatic? What type of asthma inhaler do you use?

What sort of psychiatric care have you received? When? Were you diagnosed with anything? Were you given any medications? Please explain.

Which family member(s) have/had a mental illness or disease? Which illness/disease?

Please explain the accident or head injury. Did you lose consciousness? For how long?

Do you track your menstrual cycle?

How often do you track your menstrual cycle?

What method(s) do you use to track your cycle? Choose all that apply.

If other, explain:

Date of your most recent period:

Date of your second most recent period:

Date of your third most recent period:

Do you have a regular menstrual cycle? (Bleeding once per month)

Average length of cycle (time between menses)?

Average length of bleeding during menses?

Have you ever experienced irregular or abnormally long (>35 days) menstrual cycles?

Have you ever missed more than 3 periods in a row?

Have you ever been diagnosed with polycystic ovarian syndrome (PCOS)?

Have you taken any reproductive hormone in the past 3 months (e.g., contraception - birth control pills/patches/IUD/injections/implant; fertility treatment; hormone replacement therapy)?

Are you planning to take any reproductive hormones in the next 3 months?

Are you currently using any medications, inhalers, patches, or hormone replacements (other than what you may have reported above)?

Are you currently pregnant or do you plan to become pregnant within the next few months?

Have you been pregnant and/or breastfeeding within the past 6 months?

How many times per week do you typically drink alcohol?

How many drinks per time?

What kind? (example: Beer, Hard Liquor, etc.)

Antihistamines (medications for allergies)

Sedatives (anti-anxiety agents such as Valium)

Please specify what medication.

Please specify how often.

When was the most recent time?

Is it a prescription?

Aspirin, Tylenol, other pain relievers

Please specify how often.

Antacids

How often? Please explain.

Health Food Supplements/Remedies (melatonin, herbal ecstasy, ginseng)

Please specify which supplement or product you take.

How often do you take this supplement?

When was the last time you took the supplement?

Is it prescription?

When was the most recent time you used marijuana?

When was the most recent time you used cocaine?

When was the most recent time you used amphetamines?

What type?

Were/are they prescribed to you?

When was the most recent time you used ecstasy?

When was the most recent time you used sleeping pills?

What type of sleeping pills?

Were/are they prescribed to you?

When was the most recent time you used LSD or mushrooms?

When was the most recent time you used steroids?

Are you able to stop during, and 3 weeks prior to, the study?

This includes all drugs, medicines, alcohol, caffeine, nicotine products, chocolate, herbal remedies, etc.

Do you have any problems with your sleep?

What kind? Please describe.

How frequently?

How many hours do you typically sleep on weekdays?

How many hours do you typically sleep on weekends?

For how long (years, months) has this been your typical sleep duration?

How many hours of sleep do you think you need to feel well rested?

Do you feel your sleep is inadequate or insufficient in some way?

Why?

Typical Bedtime
(WEEKDAYS)

Typical Waketime
(WEEKDAY)

Typical Bedtime
(WEEKENDS)

Typical Waketime
(WEEKENDS)

Would you be able to keep a regular 10-hour sleeping schedule for at least one week prior to staying in the lab?

When was the last time you stayed up all night (or much later than usual)?

Aside from the above questions, is there anything else that you would like us to know in order for us to help determine your eligibility?

Best email address to contact you:

Best phone number to contact you:

Text messages by mobile/cell phones are a common form of communication. This research study involves sending you text messages that are relevant to the research study. Texting over mobile/cell phones carries security risks because text messages to mobile/cell phones are not encrypted. This means that information you send or receive by text message could be intercepted or viewed by an unintended recipient, or by your mobile/cell phone provider or carrier.

Below are some important points about texting in this research study.

• Text messages are not encrypted, and therefore carry security risks. This research study and Mass General Brigham are not responsible for any interception of messages sent through unencrypted text message communications.

• You will be responsible for all fees charged by your carrier's service plan for text messaging. This research study and Mass General Brigham are not responsible for any increased charges, data usage against plan limits or changes to data fees from the research texts (Include language if participants are paid/given stipends to cover potential charges).

• Text messages will only be read during regular business hours. Texts sent on nights or weekends will not be read until the next business day.

• Text messaging should not be used in case of an emergency. If you experience a medical emergency, call 911 or go to the nearest hospital emergency department.

• You may decide to not send or receive text messages with staff associated with this research study at any time. You can do this in person or by sending the research number a text message that says "Stop Research Text."

• Your agreement applies to this research study only. Agreeing to other texts from Mass General Brigham, for example appointment reminders, is a separate process. Opting out of other texts from Mass General Brigham is a separate process as well.

• It is your responsibility to update your mobile/cell phone number with this research study in the event of a change.

I have been informed of the risks and other information covered above and consent to the use of unencrypted text communications associated with this research study.