Insomnia

Interested in participating in a insomnia study?

Fill out the form below to see if you qualify.

First Name*

Last Name*

Phone Number*

Email*

Age*

Height*

Weight*

Do you have difficulty falling asleep?
yesno


How long does it usually take you to fall asleep?


Do you have difficulty staying asleep?
yesno


​How long have you had trouble falling asleep?


​​Do you feel tired during the day?
yesno


​​Do you have any other medical conditions?
yesno


If yes, please list the medical conditions


What medications do you take?


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