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This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

jLcKXoKy3UNb9VVdxV4z67oVcXzWFXELD6Vb8fTVqYHQYExtWXQ3aWCn98pALe2UVmAZNc5MkAujUUUtPzvAmVQ4TG

Pre-Screening Survey

Please answer the questions below to the best of your knowledge. Identifiable information will be collected at the end of the questionnaire.

If it looks like you might be eligible, we will provide you with details about the study and prompt you to fill out a more extensive set of questionnaires prior to enrollment.

Some of the questions below will be personal or confidential. All questions are IRB approved. This questionnaire will take approximately 10 minutes.

If you have any questions, please contact us as clinphys@ohsu.edu or 503-494-5536.

Thank you!

Age

* must provide value

This question asks about gender. Gender is the internal sense of how we identify as either a man, woman, neither, both, non-binary or non-conforming, terms that are often used to describe any identity that doesn't fit neatly into the categories of man or woman.

How do you currently identify your gender? (mark all that apply)

* must provide value

Cisgender Man

Cisgender Woman

Genderqueer

Gender Non-conforming, Gender Non-binary

Man

Transgender Man/Trans Man

Transgender Woman/Trans Woman

Two-Spirit

Woman

Additional category, please specify below

Decline to Answer

What is your sex assigned or assumed at birth: (select ALL that apply)

* must provide value

Female

Male

Intersex

Something else not listed: (please specify)

Prefer not to state

This question is about the sex that was assigned to you at birth. Your sex assigned at birth, is generally done when a health care provider examines a baby's genitals (sex organs).

What was your sex assigned at birth?

* must provide value

Female

Male

Intersex

Decline to answer

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Please specify an additional catergory not listed above for gender:

Weight (pounds)

* must provide value

Height (inches)

* must provide value

Have you ever been diagnosed with a chronic medical condition (e.g. diabetes, high blood pressure, cancer)?

* must provide value

Yes

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What condition(s)?

* must provide value

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Have you been diagnosed with a psychological disorder?

* must provide value

Yes

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What disorder(s)?

* must provide value

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Are you taking any prescription or non-prescription medications?

* must provide value

Yes

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What medication(s)?

* must provide value

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Are you pregnant?

* must provide value

Yes

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How many hours, on average, do you sleep per night?

* must provide value

What time do you usually go to bed on weekdays (e.g. 11 pm)?

* must provide value

What time do you usually wake up on weekdays (e.g. 7am)?

* must provide value

What time do you usually go to bed on weekends (e.g. 12 am)?

* must provide value

What time do you usually wake up on weekends (e.g. 8 am)?

* must provide value

Do you take naps?

* must provide value

Yes

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How long do you nap on average (minutes) per day?

* must provide value

Have you been diagnosed with any sleep disorders?

* must provide value

Yes

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What disorder(s)?

* must provide value

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Have you done shift work in the past year?

* must provide value

Yes

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What type of work and what were the hours?

* must provide value

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Do you have a history of smoking or tobacco use?

* must provide value

Yes

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What form and for how long? Please indicate if currently using (within past 6 months).

* must provide value

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Do you have a history of drug use including cannabis?

* must provide value

Yes

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Please specify which drug(s) and last date(s) of use. Please indicate if currently using (within past 6 months).

* must provide value

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Are you currently using cannabis?

* must provide value

Yes

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Would you be willing to discontinue cannabis use for approximately 30 days prior to enrollment in the study?

* must provide value

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.