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Required format:

srSUvSGJ7L6MUVZWR2aQWhQiXKI2Ya6A5j5jMZ

Metabolic Impact of Intermittent CPAP Screening Questionnaire

We are doing this research study to see how sleep apnea affects metabolism. If you choose to participate in this study, you will be asked to come to the sleep lab for two visits. During one visit, you will wear CPAP. On another night, you will wear a nasal dilator strip instead of CPAP. The research study also involves blood work, a bone (DEXA) scan, and diabetes tests. You will be paid up to $525 for completing the study.

Why are you taking this survey?

* must provide value

I have sleep apnea and I am interested in being a participant in this study

I am a healthcare provider referring my patient for this study

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First name of participant:

* must provide value

Last name of participant:

* must provide value

Date of birth of participant:

* must provide value

M-D-Y

Thank you for referring your patient for potential enrollment in the "Metabolic Impact of Intermittent CPAP" study! Please acknowledge that you have documented in the chart that your patient is interested in being contacted about this study for further information.

* must provide value

Yes No

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Where did you learn about the study?

* must provide value

Facebook Study flyer Johns Hopkins website Not sure Other

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Are you between the age of 20 - 75?

* must provide value

Yes No

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Have you been diagnosed with sleep apnea?

* must provide value

Yes No

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Do you use CPAP regularly?

* must provide value

Yes No

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Do you have uncontrolled high blood pressure (170/110 or higher)?

* must provide value

Yes No

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Have you ever been diagnosed with congestive heart failure?

* must provide value

Yes No

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Do you take Clonidine (Catapres, Catapres-TTS-1, Catapres-TTS-2), OR Nicotinic acid (Niacin, Niacin Flush Free, Niacin No Flush)?

* must provide value

Yes No

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Do you have diabetes requiring the use of insulin?

* must provide value

Yes No

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Are you a commercial driver or pilot?

* must provide value

Yes No

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Are you able to take time off work in order to abstain from CPAP?

* must provide value

Yes No

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Thank you for your interest in our research study, but unfortunately you do not qualify to participate.

Based on your answers, you may qualify for this research study.

If you are interested in participating, please provide us with contact info, and a study team member will be in touch with you within 2-3 business days.

Would you like to proceed in order to speak with a study team member?

* must provide value

Yes

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Phone number:

* must provide value

Email address:

* must provide value

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.