Phone Screen Survey

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?

Your Name:

Phone Number:

Email Address:

Preferred methods of contact:
(you can select multiple methods)

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?

Are you legally allowed to accept payment for this study?

Do you want to be contacted about any future studies from the Division of Sleep Medicine?

Do you want to be contacted about any future studies from Brigham and Women's Hospital?

Which protocol are you interested in screening for?

How did you hear about our study?

Age:

Height: (inches)

Weight: (pounds)

BMI:

Gender:

Do you currently have a regular monthly menstrual cycle?

Are you on any form of birth control?

If yes, what kind?

If yes, was the birth control started or changed in the last 3 months?

Where do you live? (city, state)

What is your race?

What is your ethnicity?

Are you on any prescribed medications?

Do you have any medical conditions or problems?

Are you a current smoker?

Did you smoke in the past?

How many years of smoking?

When did you last smoke?

Do you have any artificial parts? (e.g. heart stents, joints, screws)

Have you been diagnosed with a sleep disorder?

What sleep disorder?

Please indicate your habitual bedtime (when you try to fall asleep) on your work days/week days:

Please indicate your habitual wake time on your work days/week days:

Please indicate your habitual bedtime (when you try to fall asleep) on your days off/weekends:

Please indicate your habitual wake time on your days off/weekend:

Have you ever pulled all-nighters?

How many all-nighters have you had in the last 12 months?

How many all-nighters have you had in the last 30 days?

Do you take naps?

How many hours (cumulatively) per week do you nap?

Have you worked the night shift (11pm-7am) within the past year?

When was the last time you worked the night shift?

Have you ever had heart disease or heart murmur?

Have you ever had high cholesterol?

If yes, what are your fasting values?

Have you ever had lung disease?

Have you ever had kidney disease?

Have you ever had visual or hearing impairment (including glasses and contacts)?

Have you ever had any eye injuries?

Are you color blind?

Have you ever had any neurological disease (ex. Stroke, recurrent migraines)?

Have you ever had any stomach or intestinal disease (ex. ulcers)?

Have you ever had any accidents/head injuries/loss of consciousness or memory?

Have you had any thyroid disease?

Have you had diabetes?

Have you had hepatitis?

Do you have the Hepatitis B vaccine?

Have you had asthma?

If yes, are you currently being treated?

If yes, what treatment are you using?

Have you ever fainted or felt light headed at the sight of blood or during a blood draw?

Have you had hemorrhoids?

Have you had any kind of surgery?

What kind of surgery?

Do you have a latex allergy?

Have you had any type of psychiatric care or counseling?

What was the reason?

What was your diagnosis (if any)?

How long ago did you receive care?

Any mental illness in the family?

If yes, who in your family?

History of attempted suicide in yourself or your family?

If yes, yourself or who in your family?

Are you a vegetarian or vegan?

Do you have any food allergies?

If yes, what allergies do you have?

How many times a day do you have coffee?

How many times a day do you have tea?

How many times a day do you have soda or energy drinks?

How many times a week do you have chocolate?

Are you willing to refrain from caffeine consumption for the duration of this study?

How many alcoholic drinks do you have in a week?

Are you willing to refrain from alcohol for the duration of this study?

Do you currently use or have you ever used anti-anxiety medications?

Do you currently use or have you every used anti-depressant medications?

Do you currently use or have you ever used high cholesterol medication?

Do you currently use or have you ever used allergy medication (antihistamines e.g. Benedryl)?

If yes, how often?

Do you currently use or have you ever used pain relievers (e.g. aspirin, tylenol, advil)?

If yes, how often?

Do you currently use or have you ever used food supplements or herbal remedies?

Do you currently use or have you ever used antacid medications (e.g. prilosec) ?

Do you currently use or have you ever used anti-epileptic medications?

Do you currently use or have you ever used antipsychotic medications?

Do you currently use or have you ever used oral steroids?

Do you currently use or have you ever used topical steroids?

Do you currently use or have you ever used marijuana?

How many times a week do you use marijuana?

Do you currently use or have you ever used speed, other amphetamines, crystal meth or ecstasy?

How many times have you used it in your lifetime? When was your last use ?

Do you currently use or have you ever snorted or smoked cocaine or crack?

How many times have you used it in your lifetime ? When was your last use?

Do you currently use or have you ever used hallucinogens (LSD, mushrooms, peyote, mescaline, PCP)?

How many times have you used it in your lifetime ? When was your last use?

Do you currently use or have you ever used heroin?

How many times have you used it in your lifetime ? When was your last use?

Do you currently use or have you ever used other opiates (narcotics. morphine, opium)?

How many times have you used it in your lifetime ? When was your last use?

Do you currently use or have you ever used tranquilizers (valium, librium)?

How many times have you used it in your lifetime ? When was your last use?

Do you currently use or have you ever used downers or quaaludes (barbituates)?

How many times have you used it in your lifetime ? When was your last use?

Do you currently use or have you ever used inhalants/things you huff (glue, paint, laughing gas, nitrous)?

How many times have you used it in your lifetime ? When was your last use?

Do you currently use or have you ever used prescribed sleeping pills (lunesta, ambien)?

Do you currently use or have you ever used over the counter sleeping meds (melatonin, nyquil, tylenol PM)?

How often?

Have you ever injected any substance ever?

Have you ever been on hormonal therapy?

Have you participated in any research study?

When and where?

Have you traveled outside the time zone within the last 3 months?

Where and when did you travel?

Are you planning on traveling outside the time zone in the next two months?

Where are you traveling and for how long?

Have you donated blood in the past 8 weeks?