This study is conducted by the Sleep and Chronobiology Laboratory at the University of Colorado at Boulder.
Checking "I agree" documents that you have read the information about the study and give your permission to take part in the initial screening for this research.
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I agree
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What is your name?
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What is your sex?
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Female Male
What is your address?
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What is your phone number?
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What is your email address?
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How old are you?
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What is your date of birth (MM-DD-YYYY)?
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Today M-D-Y
What is your current occupation?
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Are you a full time student?
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Yes
No
On average, how many hours per week do you work?
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What month(s) would you be available to spend 5 consecutive weeks participating in the study?
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Have you ever participated in a research study?
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Yes No
What type of research study did you participate in?
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When did you participate in a research study?
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Did the research study involve blood draws? If so, how much blood did you donate?
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Did the research study involve taking medication? If so, please list the name of the medication.
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How tall are you (feet, inches)?
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How much do you weigh (in pounds)?
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How long have you weighed this much?
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What is the most that you have weighed in your lifetime, excluding pregnancy (in pounds)?
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Do you exercise regularly?
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Yes No
How often do you exercise?
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What type of exercise do you do?
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Which is your dominant hand?
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Left Right Both
Have you ever been diagnosed with a medical problem or illness?
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Yes No
What medical problem(s) or illness(es) have you been diagnosed with, and when did this occur?
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Have you ever been diagnosed with a psychological or psychiatric problem or illness?
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Yes No
What psychological or psychiatric problem(s) or illness(es) have you been diagnosed with, and when did this occur?
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Do you use any prescription medication?
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Yes No
Please provide the name of the medication(s), dose, length of use, and the reason you are using it.
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Do you use hormones (e.g. contraceptive birth control), inhalers, or medicated patches (e.g. birth control, nicotine)?
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Yes No
Please provide the name of the hormone, inhaler, or patch, the dose, how long you have been using it, and for what purpose.
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Next is a series of questions about your medical history. Please indicate if you have now or have ever had any of the following conditions. If your response is "Yes" to a question, please explain when the problem was identified or diagnosed, what treatment you use(d) for it and when, and whether you experienced any complications from it.
Have you ever had or do you currently have heart disease or a heart murmur?
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Yes No
What heart disease(s) or murmurs have you had? When were they identified? If they are treated, how? Have you had any complications from this?
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Have you ever had or do you currently have any type of lung disease?
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Yes No
What lung disease(s) have you had? When were they identified? If they are treated, how? Have you had any complications from this?
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Have you ever had or do you currently have any type of kidney disease?
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Yes No
What kidney disease(s) have you had? When were they identified? If they are treated, how? Have you had any complications from this?
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Have you ever had any type of stomach or intestine disease [e.g. ulcers, acid reflux, Irritable Bowl Syndrome (IBS)]?
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Yes No
What stomach disease have you had? When were they identified? If they are treated, how? Have you had any complications from this?
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Have you ever had and do you currently have any type of visual impairment?
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Yes No
What type of visual impairment did you have or do you currently have?
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Do you wear contact lenses or glasses?
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Yes No
What type of corrective lenses do you use?
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Primarily contact lenses Primarily eyeglasses Both contact lenses and eyeglasses
Have you had any eye injuries?
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Yes No
What type of eye injury have you had? When did this occur? If it was treated, how? Have you had any complications from this?
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Are you colorblind?
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Yes No I don't know
What type of colorblindness do you have?
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Do you have any hearing impairments?
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Yes No
What type of hearing impairment do you have?
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Have you ever had any type of neurological disease (e.g. stroke, seizures, migraine headaches)?
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Yes No
What type of neurological disease have you had? When was it identified? If it is treated, how? Have you had any complications from this?
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Have you ever been diagnosed with peripheral neuropathy associated with cold intolerance, numbness and skin color changes in the hands, complex regional pain syndrome (CRPS), Raynaud phenomenon, occlusive vascular disease of the hand, acrocyanosis, erythromelalgia, or metabolic or autoimmune diseases that affect digital blood flow?
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Yes No
Have you experienced accidents, head injuries, concussions, or loss of consciousness?
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Yes No
What was the nature of your accident, head injury, or concussion? What length of time did you lose consciousness for, if at all? When did the incident occur, what (if any) treatment have you undergone for it, and have you experienced any long term complications because of it?
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Have you ever had or do you currently have thyroid disease (e.g. hyper or hypothyroidism)?
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Yes No
What type of thyroid disease have you had? When was it identified? If it is treated, how?
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Have you had or do you have high blood pressure?
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Yes No
Do you have diabetes?
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Yes No
Do you have hepatitis?
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Yes No I don't know
What type of hepatitis do you have?
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Have you ever had or do you now have asthma?
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Yes No
Has your asthma been influenced by age, physical activity, or temperature? How do you manage or treat it?
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Have you ever had surgery?
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Yes No
What type of surgery? When? Was local or general anesthesia used? Did you have any complications following the surgery?
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What type of caffeine do you typically consume? (Check all that apply)
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coffee - caffeinated
tea - caffeinated
soft drinks
energy drinks
chocolate
I do not consume any caffeine
How much caffeinated coffee do you drink and how often? Please specify the size of the drink (e.g. 8 oz., or Starbucks Grande size), and the number you consume per day, week, or month.
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How much caffeinated tea do you drink and how often? Please specify the size of the drink (e.g. 8 oz., or 1 mug) and the number you consume per day, week, or month.
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How many caffeinated soft drinks do you consume, and how often? Please specify the size of the drink (e.g. one 12 ounce can or one 20 ounce bottle) and how many you consume per day, week, or month.
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Please specify the energy drink you use, the size, and how many you consume per day, week, or month.
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How much chocolate do you eat and how often?
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Please indicate if you use the following: (check all that apply)
Sedatives (i.e. valium, sleeping pills, anti-anxiety pills)
Antihistamines (i.e. allergy medicine)
Pain relievers (e.g. Aspirin, Tylenol, Ibuprofen)
Antacids
What type of sedatives do you use, what dose, how often, and for what purpose?
What antihistamines do you use, what dose, how frequently, and for what purpose?
What type of pain reliever do you use, what dose, how frequently, and for what purpose?
What type of antacid do you use, how frequently, and for what purpose?
Do you drink alcohol?
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Yes No
On average, how many days per week do you drink alcohol, and how much do you drink on each occasion?
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Do you ever use tobacco?
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Yes No
What type of tobacco do you use? (check all that apply)
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Chewing tobacco
Cigarettes
Cigars
Pipe
Hookah
How long have you chewed tobacco, how much, and how often do you chew?
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How long have you smoked cigarettes, how many cigarettes do you smoke per day, and have you ever quit smoking (if yes, provide details like when and for how long you stopped)?
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How long have you smoked cigars, pipe tobacco, or hookah and how much do you smoke per day?
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Do you currently use marijuana?
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Yes
No
How long have you used marijuana, how much, and how often?
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Do you have any problems with your sleep?
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Yes No
What type of problems do you have with your sleep?
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How long does it usually take you to fall asleep?
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How many hours do you sleep in an average night?
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What is your usual bedtime on weekdays?
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What is your usual wake time on weekdays?
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What is your usual bedtime on weekends?
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What is your usual wake time on weekends?
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Do you ever take naps?
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Yes
No
How many naps do you take during a week? How long is each nap?
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Have you traveled outside of the mountain time zone within the past 3 months?
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Yes No
Where did you go, for how many days, and what date did you return?
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Do you have future travel plans that may conflict with participation in this study; if so, when, for how many days, and to where?
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As of today, how long have you lived at the altitude of Denver or higher?
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How did you hear about this research study?
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CU Boulder Buff Bulletin CU Boulder Today Craigslist Indeed Research Match Reddit Facebook Online Banner Ad (Various Websites) Flyer Word of mouth Other
Do you use hormonal contraceptives?
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Yes No
What type of hormonal contraceptive do you use?
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How long have you been using this hormonal contraceptive?
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How many days are there from the start of one menstrual period to the start of the next menstrual period for you?
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What was the start date of your last menstrual cycle?
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Today M-D-Y
What was the start date of your menstrual cycle prior to that? (e.g. your second-to-last menstrual cycle)
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Today M-D-Y
Is the number of days between your menstrual period consistent from month to month?
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Yes No
Please explain how the length of time between your menstrual periods varies from month to month.
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Have you given birth in the past year?
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Yes No
Are you currently breastfeeding?
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Yes No
Please check all of the following dietary descriptions that apply to you:
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Vegetarian
Vegan
Gluten sensitivity or allergy
Dairy sensitivity or allergy
Other food allergies, sensitivities or restrictions
No food allergies, sensitivities or restrictions
I give my permission for my information to be included in the study recruitment database to take part in other current studies I may qualify for, or for future research.
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Yes No
Initials
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If I answered yes, I understand that I may later change my mind, and that I can contact the Sleep and Chronobiology Staff in writing to have my contact information destroyed.
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