Any personal and identifying information asked during this phone screen will need to be stored in the Division of Sleep Medicine Database.
Do you give us permission to enter your contact information into our Database?
* must provide value
Yes
No
Your Name:
* must provide value
Phone Number:
* must provide value
Email Address:
* must provide value
Preferred methods of contact:
(you can select multiple methods)
* must provide value
Phone call
Email
Text
To enroll in the study our team will need to associate you with our study in an electronic database that is used by the Partners Healthcare system. When we access this database we will see summary information about your medical history. Do you give me permission to access this database?
* must provide value
Yes
No
Are you legally allowed to accept payment for this study?
* must provide value
Yes
No
Do you want to be contacted about any future studies from the Division of Sleep Medicine?
* must provide value
Yes
No
Do you want to be contacted about any future studies from Brigham and Women's Hospital?
* must provide value
Yes
No
Which protocol are you interested in screening for?
* must provide value
Protocol 1 (5 day stay, $1,700) Protocol 2 (3 separate 2 day stays, $2,100) Both
How did you hear about our study?
* must provide value
Harvard website Clinical Trials Brigham website Craigslist Metro Other
Height: (inches)
* must provide value
Weight: (pounds)
* must provide value
View equation
Gender:
* must provide value
Male Female
Do you currently have a regular monthly menstrual cycle?
* must provide value
Yes No Post-Menopausal
Are you on any form of birth control?
* must provide value
Yes
No
If yes, what kind?
* must provide value
If yes, was the birth control started or changed in the last 3 months?
* must provide value
Yes
No
Where do you live? (city, state)
* must provide value
What is your race?
* must provide value
American Indian/Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White
What is your ethnicity?
* must provide value
Hispanic or Latino Not Hispanic or Latino
Are you on any prescribed medications?
* must provide value
Do you have any medical conditions or problems?
* must provide value
Are you a current smoker?
* must provide value
Yes
No
Did you smoke in the past?
* must provide value
Yes
No
How many years of smoking?
* must provide value
When did you last smoke?
* must provide value
Do you have any artificial parts? (e.g. heart stents, joints, screws)
* must provide value
Yes
No
Have you been diagnosed with a sleep disorder?
* must provide value
Yes
No
What sleep disorder?
* must provide value
Please indicate your habitual bedtime (when you try to fall asleep) on your work days/week days:
* must provide value
Now H:M
Please indicate your habitual wake time on your work days/week days:
* must provide value
Now H:M
Please indicate your habitual bedtime (when you try to fall asleep) on your days off/weekends:
* must provide value
Now H:M
Please indicate your habitual wake time on your days off/weekend:
* must provide value
Now H:M
Have you ever pulled all-nighters?
* must provide value
Yes
No
How many all-nighters have you had in the last 12 months?
* must provide value
How many all-nighters have you had in the last 30 days?
* must provide value
Do you take naps?
* must provide value
Yes
No
How many hours (cumulatively) per week do you nap?
* must provide value
Have you worked the night shift (11pm-7am) within the past year?
* must provide value
Yes
No
When was the last time you worked the night shift?
* must provide value
Have you ever had heart disease or heart murmur?
* must provide value
Yes
No
Have you ever had high cholesterol?
* must provide value
Yes
No
If yes, what are your fasting values?
* must provide value
Have you ever had lung disease?
* must provide value
Yes
No
Have you ever had kidney disease?
* must provide value
Yes
No
Have you ever had visual or hearing impairment (including glasses and contacts)?
* must provide value
Yes
No
Have you ever had any eye injuries?
* must provide value
Yes
No
Are you color blind?
* must provide value
Yes
No
Have you ever had any neurological disease (ex. Stroke, recurrent migraines)?
* must provide value
Yes
No
Have you ever had any stomach or intestinal disease (ex. ulcers)?
* must provide value
Yes
No
Have you ever had any accidents/head injuries/loss of consciousness or memory?
* must provide value
Yes
No
Have you had any thyroid disease?
* must provide value
Yes
No
Have you had diabetes?
* must provide value
Yes
No
Have you had hepatitis?
* must provide value
Yes
No
Do you have the Hepatitis B vaccine?
* must provide value
Yes
No
Have you had asthma?
* must provide value
Yes
No
If yes, are you currently being treated?
* must provide value
Yes
No
If yes, what treatment are you using?
* must provide value
Have you ever fainted or felt light headed at the sight of blood or during a blood draw?
* must provide value
Yes
No
Have you had hemorrhoids?
* must provide value
Yes
No
Have you had any kind of surgery?
* must provide value
Yes
No
What kind of surgery?
* must provide value
Do you have a latex allergy?
* must provide value
Yes
No
Have you had any type of psychiatric care or counseling?
* must provide value
Yes
No
What was the reason?
* must provide value
What was your diagnosis (if any)?
* must provide value
How long ago did you receive care?
* must provide value
Any mental illness in the family?
* must provide value
Yes
No
If yes, who in your family?
* must provide value
Parent Sibling Child Other
History of attempted suicide in yourself or your family?
* must provide value
Yes
No
If yes, yourself or who in your family?
* must provide value
Yourself Parent Child Sibling Other
Are you a vegetarian or vegan?
* must provide value
No Vegetarian Vegan
Do you have any food allergies?
* must provide value
Yes
No
If yes, what allergies do you have?
* must provide value
How many times a day do you have coffee?
* must provide value
0 1 2 3 4 5+
How many times a day do you have tea?
* must provide value
0 1 2 3 4 5+
How many times a day do you have soda or energy drinks?
* must provide value
0 1 2 3 4 5+
How many times a week do you have chocolate?
* must provide value
0 1 to 4 4 to 8 9+
Are you willing to refrain from caffeine consumption for the duration of this study?
* must provide value
Yes
No
How many alcoholic drinks do you have in a week?
* must provide value
0 1 to 5 5 to 9 10 to 14 15+
Are you willing to refrain from alcohol for the duration of this study?
* must provide value
Yes
No
Do you currently use or have you ever used anti-anxiety medications?
* must provide value
Yes
No
Do you currently use or have you every used anti-depressant medications?
* must provide value
Yes
No
Do you currently use or have you ever used high cholesterol medication?
* must provide value
Yes
No
Do you currently use or have you ever used allergy medication (antihistamines e.g. Benedryl)?
* must provide value
Yes
No
If yes, how often?
* must provide value
5+ times a week 2-4 times a week 1-4 times a month < 1 time a month
Do you currently use or have you ever used pain relievers (e.g. aspirin, tylenol, advil)?
* must provide value
Yes
No
If yes, how often?
* must provide value
5+ times a week 2-4 times a week 1-4 times a month < 1 time a month
Do you currently use or have you ever used food supplements or herbal remedies?
* must provide value
Yes
No
Do you currently use or have you ever used antacid medications (e.g. prilosec) ?
* must provide value
Yes
No
Do you currently use or have you ever used anti-epileptic medications?
* must provide value
Yes
No
Do you currently use or have you ever used antipsychotic medications?
* must provide value
Yes
No
Do you currently use or have you ever used oral steroids?
* must provide value
Yes
No
Do you currently use or have you ever used topical steroids?
* must provide value
Yes
No
Do you currently use or have you ever used marijuana?
* must provide value
Yes
No
How many times a week do you use marijuana?
1 2 3 4 5+
Do you currently use or have you ever used speed, other amphetamines, crystal meth or ecstasy?
* must provide value
Yes
No
How many times have you used it in your lifetime? When was your last use ?
* must provide value
Do you currently use or have you ever snorted or smoked cocaine or crack?
* must provide value
Yes
No
How many times have you used it in your lifetime ? When was your last use?
* must provide value
Do you currently use or have you ever used hallucinogens (LSD, mushrooms, peyote, mescaline, PCP)?
* must provide value
Yes
No
How many times have you used it in your lifetime ? When was your last use?
* must provide value
Do you currently use or have you ever used heroin?
* must provide value
Yes
No
How many times have you used it in your lifetime ? When was your last use?
* must provide value
Do you currently use or have you ever used other opiates (narcotics. morphine, opium)?
* must provide value
Yes
No
How many times have you used it in your lifetime ? When was your last use?
* must provide value
Do you currently use or have you ever used tranquilizers (valium, librium)?
* must provide value
Yes
No
How many times have you used it in your lifetime ? When was your last use?
* must provide value
Do you currently use or have you ever used downers or quaaludes (barbituates)?
* must provide value
Yes
No
How many times have you used it in your lifetime ? When was your last use?
* must provide value
Do you currently use or have you ever used inhalants/things you huff (glue, paint, laughing gas, nitrous)?
* must provide value
Yes
No
How many times have you used it in your lifetime ? When was your last use?
* must provide value
Do you currently use or have you ever used prescribed sleeping pills (lunesta, ambien)?
* must provide value
Yes
No
Do you currently use or have you ever used over the counter sleeping meds (melatonin, nyquil, tylenol PM)?
* must provide value
Yes
No
How often?
* must provide value
Have you ever injected any substance ever?
* must provide value
Yes
No
Have you ever been on hormonal therapy?
* must provide value
Yes
No
Have you participated in any research study?
* must provide value
Yes
No
When and where?
* must provide value
Have you traveled outside the time zone within the last 3 months?
* must provide value
Yes
No
Where and when did you travel?
* must provide value
Are you planning on traveling outside the time zone in the next two months?
* must provide value
Yes
No
Where are you traveling and for how long?
* must provide value
Have you donated blood in the past 8 weeks?
* must provide value
Yes
No