BCFS001399-HSL-Millar-79 [Screening Form] -

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

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First Name

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Last Name

Phone Number

Email Address

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Gender

Male

Female

Other

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Date of Birth

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What city do you live in?

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What state do you live in?

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Select all of the following that best describes you:

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Do you have sleep problems (i.e., trouble falling asleep, staying asleep, or sleeping too much)?

Yes

Have you been diagnosed with any of the following sleep disorders?

Insomnia

Sleep apnea

Narcolepsy

Restless legs syndrome

Other

None of the above

Which of the following best describes your current or recent use of sleep aids or hypnotic medications (e.g., trazodone, melatonin, over-the-counter sleep aids)?

I do not currently use any sleep aids or hypnotic medications

I occasionally use over-the-counter sleep aids (e.g., melatonin, diphenhydramine)

I occasionally use prescription sleep aids or hypnotic medications (e.g., trazodone, zolpidem)

I consistently use over-the-counter sleep aids (e.g., nightly or most nights)

I consistently use prescription sleep aids or hypnotic medications (e.g., nightly or most nights)

Have you been diagnosed with type 1 or type 2 diabetes?

Yes

Do you have an allergy to cherries?

Yes

Which of the following best describes your daily consumption of caffeinated beverages (e.g., coffee, tea, energy drinks, sodas)?

I do not consume caffeinated beverages

I consume 1–2 cups of caffeinated beverages per day

I consume 3–5 cups of caffeinated beverages per day

I consume more than 5 cups of caffeinated beverages per day

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