Skip to content
Screening Form
Please complete the screening form below
First Name
Hide on Form
Last Name
Hide on Form
Phone Number
Email Address
Gender
Show on Form
Male
Female
Date of Birth
Hide on Form
What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
What category 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
What is your gender?
Male
Female
Other
BMI question
Standard
Height
Weight
Are you between 18 and 35 years old?
Yes
No
Do you typically have regular sleep patterns, with 7-9 hours of sleep per night and bedtime between 9:00 PM and 2:00 AM?
Yes
No
Do you have a regular menstrual cycle with a duration of 26-35 days?
Yes
No
N/A
Are you able to be drug-free, including caffeine, nicotine, and alcohol, for the entire duration of the study?
Yes
No
Are you currently using any form of hormonal birth control or have you used any hormonal/fertility medication in the past 3 months?
Yes
No
Have you been diagnosed with any sleep disorders, including sleep apnea, restless legs syndrome, insomnia, or narcolepsy?
Yes
No
Are you currently pregnant or breastfeeding?
Yes
No
Have you been diagnosed with ADHD or autism spectrum disorder?
Yes
No
Do you have a personal or immediate family history of psychiatric illness?
Yes
No
Have you ever been treated with antidepressants, neuroleptic medications, or major tranquilizers?
Yes
No
Are you currently taking any prescription medications other than an inhaler (if applicable)?
Yes
No
Do you currently have any diagnosis of cardiovascular, respiratory, infectious, gastrointestinal, immunological, hematopoietic, neoplastic, endocrinologic, metabolic, neurologic, or female reproductive disease or disorder?
Yes
No
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.
Captcha
Hide on Form
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00658
