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Required format:

This survey is for gauging eligibility for all of the research studies within the Sleep Neurobiology and Psychopathology (SNaP) Lab. If you appear to be eligible, someone from our team will reach out to you at our earliest convenience.

Please complete the prescreen survey below.

Thank you!

Has this prescreen been reviewed?

Has this prescreen been referred to the appropriate study?

Referred by:

Send a rejection email:

General rejection email

Apnea symptoms rejection email

Psych rejection email

medical conditions rejection email

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Team comments:

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Thank you for your interest in our study at the Sleep, Neurobiology, and Psychopathology Lab in the Department of Psychiatry at the University of Pennsylvania.

We need to ask you a few questions in order to determine whether you may be eligible for the research. Completion of this screening form will take about 10 minutes. Your participation is voluntary. A decision whether or not to participate in the screening will not affect your relationship with the University of Pennsylvania and you will not directly benefit from the screening.

Your answers will be confidential. No one will know the answers except for the research team. If you do not meet criteria at this time we will keep you on file and contact you in future if you may be eligible for an upcoming research project. If you are eligible, we will contact you in a few days to schedule you for an intake appointment.

Would you like to continue with the screening?

* must provide value

Yes No

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Thank you for your time and interest in our study.

Today's date:

M-D-Y

Name:

Phone number:

Email:

Would you prefer communication about this study to be by email or by phone?

Phone

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Home Address:

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Sex assigned at birth:

Male

Female

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Gender:

Male

Female

Non-binary

Something else

Prefer not to say

Something else (please clarify):

Date of birth:

M-D-Y

Age:

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Height:

Weight, in pounds:

BMI:

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Occupation:

Typical work shift:

Mornings

Afternoons

Business hours

Evenings

Overnight

Variable

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Do you ever work a rotating shift or the night shift?

Yes No

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If yes, please describe:

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Please check all research topics you might be interested in:

Insomnia/trouble sleeping

Depression

Post-Traumatic Stress Disorder (PTSD)

I am interested in being a healthy control

Do you consider yourself to be someone who is a good sleeper or someone who has a problem with insomnia?

I have a problem with insomnia

I am a good sleeper

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Please rate the current (i.e., last week) SEVERITY of your insomnia (trouble sleeping) problem(s).

Difficulty falling asleep:

None (< 30 min)

Mild (30-45)

Moderate (45-90)

Severe (90-120)

Very Severe (>120)

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Difficulty staying asleep:

None (< 30 min)

Mild (30-45)

Moderate (45-90)

Severe (90-120)

Very Severe (>120)

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Problem waking up too early:

None (< 30 min)

Mild (30-45)

Moderate (45-90)

Severe (90-120)

Very Severe (>120)

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How SATISFIED/dissatisfied are you with your current sleep pattern?

0 Very satisfied

4 very dissatisfied

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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.)?

Not at all Interfering

A little

Somewhat

Much

Very much interfering

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How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life?

Not at all noticeable

Barely

Somewhat

Much

Very much noticeable

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How WORRIED/distressed are you about your current sleep problem?

Not at all

A little

Somewhat

Much

Very much

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ISI Total:

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What is your typical bedtime?

H:M

How long does it typically take you to fall asleep?

Do you often have nighttime awakenings?

Yes No

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If yes, how often?

If yes, how long to fall back asleep?

What time do you typically wake up in the morning?

H:M

Do you wake up before you intend to in the morning?

Yes No

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If yes, how often?

If yes, how long before you intend to?

Do you feel rested when you wake up?

Yes No

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If you are able to choose your own bedtime and arise time, do you have any trouble sleeping?

Yes No

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Do you feel your daytime function is impaired due to insomnia?

Yes No

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Do you consider yourself to have a problem with insomnia?

Yes No

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About how long has it been a problem for you?

Did the onset of your insomnia follow a specific event?

Yes No

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If yes, please describe:

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Have you previously been treated for sleep problems?

Yes No

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If yes, please describe:

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Have you been told that you snore loudly?

Yes No

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Have you ever been told that you momentarily stop breathing or hold your breath while sleeping?

Yes No

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Do you sometimes awaken at night gasping for breath or with difficulty breathing?

Yes No

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Do you often wake up with a headache?

Yes No

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Do you often feel that you are extremely sleepy during the day such that you find yourself falling asleep, or fighting the urge to fall asleep, at inappropriate times and/or places?

Yes No

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Do you experience sudden attacks of sleep during the day (one second you're awake, then asleep)?

Yes No

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Do you sometimes experience muscular weakness if you have a strong emotion?

Yes No

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Do you sometimes awaken from nighttime sleep with terribly frightening dreams (nightmares)?

Yes No

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Do you notice an unpleasant feeling (creepy crawly) or sensation in your legs as bedtime approaches?

Yes No

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Do you currently have any medical problems?

Yes No

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If yes, please describe:

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Are you currently taking any prescription medications, over-the-counter medications, vitamins, or herbal supplements?

Yes

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Please list any prescription medications, OTC medications, vitamins, or herbal supplements you are taking, as well as the length of use, and any problems.

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Do you use any recreational drugs?

Yes No

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Specify drug type, frequency of use, last use:

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Would you be willing and able to discontinue your use while participating in the study and provide a clean urine sample?

Yes No

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Do you drink alcohol?

Yes No

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How many drinks do you have in a typical week?

Are you a nicotine/tobacco user?

Yes No

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How much do you use daily (e.g., how many packs per day)?

Do you currently or have you ever had any of the following medical conditions?

Epilepsy/serious head injury (blacked out):

Yes (current) Yes (past) No

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Cancer:

Yes (current) Yes (past) No

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Heart disease (angina, pacemaker, CABG):

Yes (current) Yes (past) No

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Kidney disease:

Yes (current) Yes (past) No

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Liver disease / hepatitis:

Yes (current) Yes (past) No

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Diabetes:

Yes (current) Yes (past) No

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Thyroid disorder:

Yes (current) Yes (past) No

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Nocturia (freq. awake to pee/urinate) or prostate disorder:

Yes (current) Yes (past) No

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Fibromyalgia:

Yes (current) Yes (past) No

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If yes to any, do you currently have the condition(s), and when were you diagnosed?

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Are you currently pregnant or breast feeding?

Yes No

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Do you currently have plans to become pregnant soon?

Yes No

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Do you regularly use birth control?

Yes No

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If yes, which specific contraceptive are you taking? (e.g., Progestin)

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Have you ever been diagnosed with the following psychiatric conditions?

Depression:

Yes (current) Yes (past) No

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Anxiety disorder:

Yes (current) Yes (past) No

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Obsessive compulsive disorder:

Yes (current) Yes (past) No

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Schizophrenia:

Yes (current) Yes (past) No

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Bipolar disorder or manic depression:

Yes (current) Yes (past) No

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Dementia:

Yes (current) Yes (past) No

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Post-Traumatic Stress Disorder (PTSD):

Yes (current) Yes (past) No

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Have you ever taken any psychiatric medications?

Yes No

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If yes, please describe:

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Have you ever been hospitalized for psychiatric reasons?

Yes No

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Have you ever been seen at the Hospital of the University of Pennsylvania?

Yes No

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If you end up not being eligible for this study, is it okay for us to keep this data to contact you about future studies you might be eligible for?

Yes No

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For comments, or if you'd like to further clarify any answers:

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If you are eligible, study staff may reach out with a brief (5 minute or so) phone call about the study. If you have a preference of when you would like to be reached, please list your preference below (e.g., Mondays 11AM):

Might be eligible for telehealth calculation

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Might be eligible for CSF calculation

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Might be eligible for SWIP calculation

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Might be eligible for TPV calculation

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Number of apnea questions answered "yes"

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May be eligible for Telehealth

May be eligible for CSF

May be eligible for SWIP

May be eligible for TPV

Participant indicated yes for Bipolar

Participant indicated yes for OCD

Participant indicated yes for Drugs/alcohol/nicotine; may need additional review

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