Sleep Research Center, Henry Ford Hospital, Detroit, MI

Qualify for a Study

If you would like to take part in a study, please fill out this short questionnaire and if you qualify you will be contacted by a research assistant.

Please fill out every field.
Personal Information

First Name
Last Name
E-Mail
Phone Number
We will only use this number to contact you regarding your survey.
Please include full 10-digit number, including area code.
Best Time to contact you
Zip/Postal Code
Must be 5 digits.
Gender
Date of Birth
Height feet inches
Weight lbs.

Lifestyle Information

Do you have difficulty sleeping?
On average, how many cigarettes do you smoke per day?
Enter 0 if you do not smoke.
On average, how many glasses of alcohol do you drink per month?
Enter 0 if you do not drink.
Where did you hear about this study?
Do you work night shifts?

Sleeping Habits

When you experience the following situations how likely is it for you to have difficulty sleeping?

Before an important meeting the next day?
After a stressful experience during the day?
After a stressful experience in the evening?
After getting bad news during the day?
After watching a frightening movie or TV show?
After having a bad day at work?
After an argument?
Before having to speak in public?
Before going on vacation the next day?

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