Answering these questions is voluntary, and you may stop at any time. However, we will need your answers to see if you qualify for the next step in the screening process.

We would like you to know how the information you share with us will be used. It will be stored in a secure database, and only shared with your permission or as required by law. If you are eligible for the next step, we will ask you to provide your contact information. We will then send this information and your answers to the study doctor and his/her staff at the center you select. Study staff will contact you to discuss the clinical study in more detail. You may withdraw your permission at any time by calling this toll-free number (1-877-444-2460) or the study center.

Do we have your permission to collect and forward your information as explained above?

• Yes
• No

Has the person you are visiting for given permission for you to provide their contact and health information?

• Yes
• No

Answering these questions is voluntary, and you may stop at any time. However, we will need your answers to see if you qualify for the next step in the screening process.

We would like you to know how the information you share with us will be used. It will be stored in a secure database, and only shared with the person you are responding for’s permission or as required by law. If the person you are responding for is eligible for the next step, we will ask you to provide contact information. We will then send this information and your answers to the study doctor and his/her staff at the center you select. Study staff will contact you and the patient to discuss the clinical study in more detail. The patient may withdraw his/her permission at any time by calling this toll-free number (1-877-444-2460) or the study center.

Do you and the patient give permission to collect and forward their information as explained above?

• Yes
• No

May I have the name of the person you are calling for?

• First Name
  
• Last Name
  

May I please have your name?

• First Name
  
• Last Name
  

What best describes your relationship with the person you are calling for?

• Spouse
• Parent
• Son/Daughter
• Relative
• Friend
• Other

To find a study center, please provide your (the patient's) zip code.

To find a study center, please provide your (the patient's) zip code.

Unfortunately there are no other study centers in this area. You can provide contact information, and you (the patient) will be contacted if a new center opens.

• Yes, I'm interested
• No, I'm not interested

Unfortunately there are no other study centers in this area. You can provide contact information, and you (the patient) will be contacted if a new center opens.

• Yes, I'm interested
• No, I'm not interested

Please provide your age and date of birth.

• Date of Birth (_ _/_ _/_ _ _ _)
  
• Age
  

Please confirm your gender.

• Male
• Female

Please provide age and date of birth.

• Date of Birth (_ _/_ _/_ _ _ _)
  
• Age
  

Please confirm gender.

• Male
• Female

Have you experienced any of the following:

• Concussion
• Head injury
• Bump to the head?

• Yes
• No

Has experienced any of the following?

• Concussion
• Head injury
• Bump to the head?

• Yes
• No

How many head injuries have you experienced? Please provide a number value.

How many head injuries has experienced? Please provide a number value.

Did you experience this head injury/any of these head injuries 1 to 10 years ago?

• Yes
• No

Did experience this head injury/any of these head injuries 1 to 10 years ago?

• Yes
• No

Did you experience any of the following after your head injury (injuries)?

• Loss of consciousness
• Loss of your memory before and after your (his/her) head injury
• Felt different or confused after the head injury
• Weakness, problems with balance, difficulty with vision or other symptoms like these

• Yes
• No

Did experience any of the following after his/her head injury (injuries)?

• Loss of consciousness
• Loss of your memory before and after your (his/her) head injury
• Felt different or confused after the head injury
• Weakness, problems with balance, difficulty with vision or other symptoms like these

• Yes
• No

Did you experience any of these symptoms for more than one of their head injuries?

• Yes
• No

Did experience any of these symptoms for more than one of their head injuries?

• Yes
• No

Were you treated by a medical professional or is there someone who could and would be willing verify what happened when this injury occurred?

• Yes
• No
• Unsure

Was treated by a medical professional or is there someone who could and would be willing to verify what happened when this injury occurred?

• Yes
• No
• Unsure

Are you currently involved in any court proceedings or receiving workman's compensation as a result of your head injury?

• Yes
• No

Is currently involved in any court proceedings or receiving workman's compensation as a result of their head injury?

• Yes
• No

Did your sleepiness during the day begin before your head injury?

• Yes
• No
• Unsure

Did sleepiness during the day began before his/her head injury?

• Yes
• No
• Unsure

Have you used or are you currently using a CPAP machine?

• Yes
• No

Has used or is he/she currently using a CPAP machine?

• Yes
• No

Are you currently taking anti-depressants for depression?

This could be medications such as, Imipramine (Tofranil), Bupropion (Wellbutrin), Amitriptyline (Elavil), Duloxetine (Cymbalta), Venlafaxine (Effexor), Citalopram (Celexa), Paroxteine (Paxil), Sertaline (Zoloft), or Fluoxetine (Prozac).

• Yes
• No

Is currently taking anti-depressants for depression?

This could be medications such as, Imipramine (Tofranil), Bupropion (Wellbutrin), Amitriptyline (Elavil), Duloxetine (Cymbalta), Venlafaxine (Effexor), Citalopram (Celexa), Paroxteine (Paxil), Sertaline (Zoloft), or Fluoxetine (Prozac).

• Yes
• No

Are you currently taking or have you taken any anticonvulsant (seizure) medicines in the last 4 months?

• Yes
• No

Is currently taking or have they taken any anticonvulsant (seizure) medicines in the last 4 months?

• Yes
• No

Are you currently taking stimulants, such as Amphetamines (Adderall), Methylphenidate (Ritalin), Pemoline (Cylert), Dextramphetamine (Dexedrin), Modafinil (Provigl), or caffeine pills to treat your sleepiness?

• Yes
• No

Is currently taking stimulants, such as Amphetamines (Adderall), Methylphenidate (Ritalin), Pemoline (Cylert), Dextramphetamine (Dexedrin), Modafinil (Provigl), or caffeine pills to treat his/her sleepiness?

• Yes
• No

Due to study requirements, you may need to stop taking or switch these medications during the study. Would you be willing to discuss this with your doctor?

• Yes
• No
• Unsure

Due to study requirements, may need to stop taking or switch his/her medications during the study. Would be willing to discuss this with his/her doctor?

• Yes
• No
• Unsure

Have you been diagnosed by a medical professional with any of the following?

• Schizophrenia
• Bipolar
• HIV Positive

• Yes
• No

Has been diagnosed by a medical professional with any of the following?

• Schizophrenia
• Bipolar
• HIV Positive

• Yes
• No

Have you been diagnosed by a medical professional with any of the following sleep conditions?

• Narcolepsy
• Obstructive Sleep Apnea (OSA)
• Shift Work Sleep Disorder (SWSD)

• Yes
• No

Has been diagnosed by a medical professional with any of the following sleep conditions?

• Narcolepsy
• Obstructive Sleep Apnea (OSA)
• Shift Work Sleep Disorder (SWSD)

• Yes
• No

Have you had brain or brainstem surgery?

• Yes
• No

Has had brain or brainstem surgery?

• Yes
• No

Do you work the night shift, such as 11pm to 7am or 12am to 12pm?

• Yes
• No

Does work the night shift, such as 11pm to 7am or 12am to 12pm?

• Yes
• No

This study requires 7 visits to the study center and 5 of those visits are overnight stays at a sleep lab. You may check with the study center for assistance with flexible scheduling and your transportation needs.

Would you be able to commit to this schedule?

• Yes
• No
• Unsure

This study requires 7 visits to the study center and 5 of those visits are overnight stays at a sleep lab. You may check with the study center for assistance with flexible scheduling and your transportation needs.

Would be able to commit to this schedule? 

• Yes
• No
• Unsure

Do you have any vacation plans in the next 5 months?

• Yes
• No

Does have any vacation plans in the next 5 months?

• Yes
• No

Please indicate your planned vacation dates.

Please indicate planned vacation dates.

Have you ever been in a sleep center before?

• Yes
• No
• Unsure

Has ever been in a sleep center before?

• Yes
• No
• Unsure

Would you be willing to not smoke cigarettes or take other forms of nicotine for 16 hours? Patients will be provided with a nicotine patch if needed.

• Yes
• No
• Do not use nicotine
• Unsure

Would be willing to not smoke cigarettes or take other forms of nicotine for 16 hours? Patients will be provided with a nicotine patch if needed.

• Yes
• No
• Do not use nicotine
• Unsure

As part of this study, you may be asked to use a study-approved method of birth control or abstain from sex? Would you be willing to do this?

• Yes
• No
• Unsure
• Postmenopausal/Sterile

As part of this study, will be asked to use a study approved method of birth control or abstain from sex. Would she willing to do this?

• Yes
• No
• Unsure
• Postmenopausal/Sterile

Are you pregnant, planning on becoming pregnant, or are you currently breastfeeding?

• Yes
• No

Is pregnant, planning on becoming pregnant, or is she currently breastfeeding?

• Yes
• No

Thank you for answering these questions. Based on the information you provided, you may be eligible to take part in this study. We will need your contact information in order to send your information to the study center you selected.

Would you like to provide your contact information?

• Yes
• No   Your name will be deleted at the end of this questionnaire to ensure that the information will remain anonymous.

Thank you for answering these questions. Based on the information you have provided, the patient may be eligible to take part in this study. We will need and/or your contact information, and we will send this information to the study center you selected.

Would you like to provide his/her contact information?

• Yes
• No   Your name will be deleted at the end of this questionnaire to ensure that the information will remain anonymous.

If the person you are visiting this website for is interested in this study, please have them visit the study website at headsleepstudy.com or call 1-877-444-2460.

The patient's doctor can tell him/her more about daytime sleepiness related to head injury. Or, you may visit centerwatch.com or clinicaltrials.gov to find a list of available studies. Thank you for your interest in this research study.

The patient's doctor can tell him/her more about daytime sleepiness related to head injury. Or, you may visit centerwatch.com or clinicaltrials.gov to find a list of available studies. Thank you for your interest in this research study.

Unfortunately some of the information you provided does not fit with this study's requirements. You can provide your contact information, and we will contact you If the requirements change for this study or another study begins for this study medicine.

Would you like to provide your contact information?

• Yes
• No   Your name will be deleted at the end of this questionnaire to ensure that your information will remain anonymous.

Unfortunately some of the information you provided does not fit with this study's requirements. You have the option of providing and/or your contact information, and we can contact the patient or you if the requirements change for this study or another study begins for this study medicine.

Would you like to provide his/her contact information?

• Yes
• No   The patient's name will be deleted at the end of this questionnaire to ensure that the information will remain anonymous.

Unfortunately, this study needs people between the ages of 18 and 65. You can provide your contact information, and we will contact you if the requirements change for this study or another study begins for this study medicine.

Would you like to provide your contact information?

• Yes
• No   Your name will be deleted at the end of this questionnaire to ensure that your information will remain anonymous.

Unfortunately, this study needs people between the ages of 18 and 65. You can provide and/or your contact information, and we will contact you if the requirements change for this study or another study begins for this study medicine.

Would you like to provide his/her contact information?

• Yes
• No   The patient's name will be deleted at the end of this questionnaire to ensure that the information will remain anonymous.

Someone from the study center will contact you shortly. They will ask additional questions, provide you with more information about the study, and answer your questions. If you need help with transportation, the study center will be glad to assist you.

Thank you for your interest in this study.

Someone from the study center will contact the patient and/or you shortly. They will ask additional questions, provide the patient and you with more information about the study, and answer the patient's as well as your questions. If you need help with transportation, the study center will be glad to assist you and the patient .

Thank you for your interest in this research study. We will contact you when a/the study center opens.

Thank you for your interest in this research study. We will contact and/or you when a/the study center opens.

Thank you for contacting the clinical research screening center.