Sleep Study

1

Full Name* This field is required.

First Name

Last Name

2

What is your sex?* This field is required.

Male

Female

3

Hidden - What is your sex?* This field is required.

Male

Female

Other

4

Date of Birth* This field is required.

Date

5

Today's Date

Date

6

Hidden - Days Calculation

7

Hidden - Age Calculation

8

Hidden - Age Form Value

9

Hidden - Age Pass/Fail

10

Do you reside in Illinois?* This field is required.

Yes

No

11

Hidden - Do you reside in Illinois?* This field is required.

Yes

No

12

Have you been diagnosed with any (other) medical condition?* This field is required.e.g. diagnosed sleep disorders, major psychiatric diagnosis (e.g., bipolar, anxiety disorders), as diagnosed by a healthcare professional, including major depressive disorder (e.g., clinical depression), immunocompromised health conditions, kidney disease

Yes

No

13

Hidden - Have you been diagnosed with any (other) medical conditions* This field is required.e.g. e.g. diagnosed sleep disorders, major psychiatric diagnosis (e.g., bipolar, anxiety disorders), as diagnosed by a healthcare professional, including major depressive disorder (e.g., clinical depression), immunocompromised health conditions, kidney disease

Yes

No

14

Please specify what medical conditions you have* This field is required.

15

Are you currently taking any medications or supplements?* This field is required.i.e. any medication or supplement e.g. daily blood pressure meds, diabetes, cholesterol, multivitamin, etc

Yes

No

16

Hidden - Are you currently taking any medications or supplements?* This field is required.

Yes

No

17

Please specify what medications or supplements you are currently taking* This field is required.If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure

18

Hidden - Please specify what medications or supplements you are currently taking* This field is required.If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure

19

Do you suffer from any allergies/intolerances?* This field is required.

Yes

No

20

Hidden - Do you suffer from any allergies/intolerance?* This field is required.

Yes

No

21

Please specify

22

Do you regularly experience poor sleep?* This field is required.

Yes

No

23

Hidden - Do you regularly experience poor sleep?* This field is required.

Yes

No

24

Do you consume more than 400mg of caffeine daily? For example, one cup of coffee contains approximately 80-100mg of caffeine* This field is required.

Yes

No

25

Hidden - Do you consume more than 400mg of caffeine daily? For example, one cup of coffee contains approximately 80-100mg of caffeine

Yes

No

27

Hidden - Calculation

28

Hidden - questionnaire form value

29

Hidden - questionnaire Pass/Fail

30

Please rate the severity of your difficulty falling asleep (from the last 2 weeks)* This field is required.

31

Please rate the severity of your difficulty staying asleep (from the last 2 weeks)* This field is required.

32

Please rate the severity of your problem waking too early (from the last 2 weeks)* This field is required.

33

How SATISFIED/dissatisfied are you with your current sleep pattern?* This field is required.

34

To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.)* This field is required.

35

How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?* This field is required.

36

How WORRIED/distressed are you about your current sleep problem?* This field is required.

37

Hidden - Calculation

38

Hidden - questionnaire value form

39

Hidden - questionnaire Pass/Fail

40

Phone Number* This field is required.

Please enter a valid phone number.

41

Email* This field is required.For contact regarding this study

example@example.com

Confirm Email

42

Would you like to be subscribed to Atlantia's database?* This field is required.Subscribing to this allows us to contact you occasionally via email with study updates or new studies

Yes, Subscribe Me

No, thank you.

43

Consent to mailing list - hidden* This field is required.

45

Consent to Privacy Notice* This field is required.We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com.

46

Score* This field is required.

47

Reason* This field is required.

48

Form Status* This field is required.