Obstructive Sleep Apnea Study

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Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code of the Potential Participant *

What is your gender?

Female

Male

Prefer Not To Say

Do you suspect you have, or have you been diagnosed with, Obstructive Sleep Apnea? *
For example: You may have suspected Obstructive Sleep Apnea if you have ever been told you stop breathing during sleep, or if you wake up gasping for air.

Yes – diagnosed with Obstructive Sleep Apnea

Yes – suspected diagnosis of Obstructive Sleep Apnea

Unsure

Have you been diagnosed (by a doctor) with any other medical conditions? *
For example: Bipolar Disorder, Major Depressive Disorder, Dementia, Epilepsy, Stroke, Parkinson’s Disorder, Lupus, Multiple Myeloma, Chronic Lymphocytic Leukemia, HIV, Hepatitis B, or Hepatitis C
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

Are you taking any medications for your Obstructive Sleep Apnea or other health conditions? *
For example: benzodiazepines, Z-drugs, zolpidem, eszopiclone, opiates, antipsychotics, phenothiazines, SUNOSI, Provigil, lisinopril, enalapril, captopril, olmesartan, losartan, valsartan, irbesartan, Nuvigil
Please list them below or type ‘none’.

Please select your height from the dropdown below. *

How much do you weigh in Lbs (pounds)? *

Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 3 to 6 months? *

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Which racial or ethnic group(s) does the Potential Participant identify with?
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic / Latino / Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Another race or ethnicity

I prefer not to answer

What is the best day/time to reach you via telephone (we know you are busy)? *

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

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The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.