First & Last Name: Date of Birth: Phone Number: Phone Provider: Email: Sex:
Please tell us how you heard about the study:
Would you like your information kept on file to be contacted for future research studies?
How do you prefer to be contacted?
How would you prefer to be contacted for automated notifications?
Are you willing to abstain from alcohol for the duration of the study?
Are you willing to take melatonin nightly as part of the study?
Do you live within 60 miles of Ann Arbor, Michigan?
Are you able and willing to travel to Ann Arbor, Michigan for multiple study visits (3-4 times)?
Are you willing to download a smartphone application for the study?
Are you willing to download a smartphone application for the study?
* must provide value
Yes No
Do you live within 60 miles of Ann Arbor, Michigan?
* must provide value
Yes No
Are you able and willing to travel to Ann Arbor, Michigan for multiple study visits (3-4 times)?
* must provide value
Yes No
Please tell us how you heard about the study:
* must provide value
Prechter Longitudinal Study Michigan Medicine Ambulatory Care Clinic Other University of Michigan Website UMHealthResearch.org website ClinicalTrials.gov website Reddit Facebook Instagram Flyer Email Other
If other, please tell us how you heard about the study:
* must provide value
If other, please tell us how you heard about the study:
Phone Provider:
* must provide value
AT&T Alltel Boost Comcast Cricket Wireless MetroPCS Nextel Sprint T-Mobile/Mint Mobile/Visible US Cellular Verizon/Xfinity/Spectrum Virgin Mobile
Preferred Auto Contact:
* must provide value
Email Text
Preferred Email for Automated Notifications:
View equation
View equation
View equation
Are you willing to abstain from alcohol for the length of the study?
* must provide value
Yes No
PHQ9 Pre-Screening Score:Inclusion Criteria: At least mild depressive symptoms on the PHQ-9 defined by a score ≥5
Hold Criteria: If pre-screener agress, contact in 4 weeks to reasses Question 9: If pre-screener answers anything but "0" contact Sarah Sperry for instructions
View equation
Mental and Behavioral Health:
Are you currently seeing a mental health professional for therapy?
Are you and your therapist currently doing Cognitive Behavioral Therapy for Insomnia and/or Social Rhythms Therapy?
What about any other types of therapy where you are working on trying to alter your sleep-wake patterns?
Example: you might be scheduling and recording your bed and wake times each week, engaging in sleep restriction, or using a light box. Description:
Exclusion Criteria: Self-reported cognitive therapy for insomnia, social rhythms therapy, or any other therapy to alter sleep-wake patterns.
Sleep Question:
Considering only your own "feeling best" rhythm, at what time would you go to bed if you were entirely free to plan your evening?
Considering only your own "feeling best" rhythm, at what time would you get up if you were entirely free to plan your day?
What time would you go to bed if you have no commitments the next day?
Eligibility Criteria: 1:00am - 2:00am or later Borderline Criteria: 11:00pm - 12:00am
Inclusion Criteria: No commitment sleep onset latency less than commitment night sleep onset latency (i.e. "On average, how many minutes does it take you to fall asleep...?")
Inclusion Criteria: Off day sleep onset latency less than work night sleep onset latency (i.e. "On average, how many minutes does it take you to fall asleep...?")
Exclusion Criteria: Self-report of routine night shift work
Sleep Information:
How long have you had problems with your sleep? Have you ever had an overnight sleep study?
Inclusion Criteria: Self-report of sleep problems lasting more than 3 months (12 weeks or 90 days)
Hold Criteria: Contact pre-screener when sleep problems would occur for 3 months Have you ever been diagnosed with:
Sleep Apnea (i.e. stop breathing during your sleep) Narcolepsy (i.e. falling asleep at random times even when you are awake and active; uncontrollable) Other Sleep Disorder (i.e. insomnia, restless leg syndrom, night terrors, etc.) Bipolar Disorder or Manic Depression
Bipolar Disorder or Manic Depression
* must provide value
Yes No
Has a doctor ever treated you for, or told you that you had:
Thyroid Condition Diabetes Type 1 or Type 2 Epilepsy/Seizures Autoimmune Disorder Hypertension or Hypotension Clotting/Bleeding Disorders
Thyroid Condition
* must provide value
Yes No
Diabetes Type 1 or Type 2
* must provide value
Yes No
Epilepsy/Seizures
* must provide value
Yes No
Autoimmune Disorder
* must provide value
Yes No
Hypertension or Hypotension
* must provide value
Yes No
Clotting/Bleeding Disorder
* must provide value
Yes No
Exclusion Criteria: Self-reported sleep disorder other than DSWPD (i.e. insomnia, sleep apnea, RLS, narcolepsy)
Medication History:
Have you taken melatonin in the last month? Have you ever had an allergic or bad reaction to melatonin? Do you use any medications or home remedies to help you sleep? Have you ever taken medications for Bipolar Disorder?
Have you ever taken medications for Bipolar Disorder?
* must provide value
Yes No
Exclusion Criteria: Self-report use of melatonin in the past month - must stop use of melatonin for at least 4 weeks before starting the study.
Hold Criteria: If pre-screener agrees to stop melatonin for 4-weeks and no other exclusionary criteria is met they can enter into "Hold" status and contacted in 4 weeks to pre-screen back into the study. Exclusion Criteria: Hypersensitivity to melatonin or any other component of the melatonin or placebo product (i.e. "Have you ever had an allergic or bad reaction to melatonin?")
Exclusion Criteria: Self-report use of sleep aid medications
Inclusion Criteria: Psychotropic medications at stable dose for past month
Hold Criteria: Re-contact to pre-screen when meds would be at stable dose for 4-weeks Current Medication List:
1. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 1?
2. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 2?
3. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 3?
4. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 4?
5. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 5?
6. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 6?
7. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 7?
8. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 8?
9. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 9?
10. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 10?
11. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 11?
12. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 12?
13. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 13?
14. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 14?
15. Medication Name: Have you started or changed the dose of this medication in the past 30 days?
When was the date you changed or started medication 15?
Exclusion Criteria: Self-report use of medications which may have an interaction with melatonin or interfere with the measurement of melatonin (not an exhaustive list - if unsure contact Leslie Swanson)
Nifedipine Anti-hypertensive medications Including, but not limited to, chlortaidone, chlorothiazide, hydrochlorothiazide, indapamide, metolazone, lisinopril, benazepril, captopril, candesartan, losartan, amlodipine, diltiazem Immunosuppressants Including, but not limited to, prednisone, budesonide, prednisolone, cyclosporine, tacrolimus, sirolimus, everolimus, azathioprine, leflunomide, mycophenolate Sedative or hypnotic medications Including, but not limited to, zolpidem, suvorexant, butabarbital, quazepam, estazolam, flurazepam, triazolam, eszopiclone, temazepam, secobarbital, doxepin, zaleplon Antidiabetic drugs Including, but not limited to, insulin, metformin, glyburide, glipizide, glimepiride, repaglinide, nateglinide, rosiglitazone, pioglitazone, canagliflozin, dapagliflozin, liraglutide Anticoagulant/antiplatelet Including, but not limited to, heparin, warfarin, rivaroxaban, dabigatran, apixaban, edoxaban, enoxaparin, fondaparinux, clopidogrel, ticagrelor, prasugrel, dipyridamole, dipryridamole/aspirin, ticlopidine, eptifibatide CYP4501A2 strong or moderate inhibitors or inducers Including, but not limited to, fluoroquinolones such as ciprofloxacin, fluvoxamine, verapamil, St. John's wort, modafinil, nafcillin, omeprazole NSAIDs if used DAILY Beta-blockers Medical History:
Do you have a cardiac implantable electronic device, such as defibrillator or pacemaker? Do you have any chronic medical illnesses?(e.g. diabetes, hypertension, seizures)
Exclusion Criteria: Presence of cardiac implantable electronic device, such as defibrillator or pacemaker
Exclusion Criteria: Presence of unstable chronic medical condition which may directly influence sleep:
Chronic pain Thyroid conditions Exclusion Criteria: Current history of medical conditions which may be affected by melatonin per self-report and medical record review (when avialable), such as:
Hypertension or hypotension Diabetes Type 1 or Type 2 Clotting/bleeding disorders Epilepsy/seizures Automimmune disorders Conditions requiring immunosuppresive management such as transplant Exclusion Criteria: Self-report of chronic psychiatric conditions which may directly influence sleep per interview and medical record review (when available), including:
Current illicit drug use Current alcohol or drug abuse History of psychotic disorder Current Chronic Medical Illness List:
1. Chronic Medical Illness:
2. Chronic Medical Illness:
3. Chronic Medical Illness:
4. Chronic Medical Illness:
5. Chronic Medical Illness:
6. Chronic Medical Illness:
7. Chronic Medical Illness:
8. Chronic Medical Illness:
9. Chronic Medical Illness:
10. Chronic Medical Illness:
11. Chronic Medical Illness:
12. Chronic Medical Illness:
13. Chronic Medical Illness:
14. Chronic Medical Illness:
15. Chronic Medical Illness:
Answer the following question for the past month:
Have you traveled outside of the eastern time zone?
Exlcusion Criteria: Self-report of past month travel across more than one time zone; must be in the eastern time zone for at least 4 weeks before starting the study
Hold Criteria: If pre-screener will meet these requirement at a future date, pre-screener may enter into "Hold" status and be contacted once they meet this requirement and not other exlusionary criteria apply Answer the following question for the next 6 weeks:
Are you planning to travel outside the eastern time zone?
Exlcusion Criteria: Self-report of planned travel during the next 6 weeks across more than one time zone; must be in the eastern time zone for the study duration
Hold Criteria: If pre-screener will meet these requirement at a future date, pre-screener may enter into "Hold" status and be contacted once they meet this requirement and not other exlusionary criteria apply General Notes to Discuss with Study Team
Pre-Screening Eligibility Status
Initial of Study Team Member: Date:
Initial of Study Team Member
Today M-D-Y
Pre-Screening Status: Is This a Duplicate Screen:
Is this a duplicate screen?
* must provide value
Yes No
Eligible Ineligible Hold
Pre-Screener marked as "Eligible". Schedule pre-screener for Consent Visit.
Did the pre-screener schedule a consent visit:
Informed Consent ScheduledSchedule the consent meeting within the BSB Calendar on SharePoint
Zoom Information:Include in zoom information ONLY the meeting URL Example: https://umich.zoom.us/ex/00000
Consent Scheduled:
* must provide value
Yes No
Informed Consent Scheduled Date:
* must provide value
Today Y-M-D
Informed Consent Scheduled Time:
* must provide value
Now H:M
View equation
Informed Consent Scheduled Zoom Info:Example: https://umich.zoom.us/ex/00000
* must provide value
Screener marked "Ineligible". Mark the exclusionary criteria the screener met based on their phone screen:
Exclusionary Criteria Met for Ineligibility:
* must provide value
No evidence of DSWPD based on reported sleep (< 1:00 AM "feeling best" bedtime)
Self-reported sleep disorder other than DSWPD (i.e. insomnia, sleep apnea, RLS, narcolepsy)
Sleep problems not occurred for more than 3 months
Minimum depressive symptoms on PHQ-9 not met (defined by a score < 5)
Self-report of cardiac implantable electronic device, such as defibrillator or pacemaker
Self-reported chronic psychiatric conditions which may directly influence sleep (i.e. current illicit drug use, current alcohol or drug abuse, or history of psychotic disorder)
Self-reported unstable chronic medical condition which may directly influence sleep (i.e. chronic pain or thyroid conditions)
Self-reported current or history of medical conditions which may be affected by melatonin (i.e. hypertension/hypotension, diabetes type 1 or type 2, clotting/bleeding disorders, epilepsy/seizures, autoimmune disorders, conditions requiring immunosuppressive management such as transplants)
Psychotropic medications not at stable dose for past month
Current use of medications which may interact with melatonin (see exclusionary medication list)
Current use of medications that may interfere with the measurement of melatonin (daily NSAID use, beta blockers)
Current use of sleep aid medications
Melatonin use in past month
Hypersensitivity to melatonin or any other components of the melatonin or placebo product
Pregnancy or breastfeeding and/or plan to become pregnant in the next 3 months
Not 18-60 years of age
Routine night shift work
Past month travel or planned travel during the study across more than one time zone
Not able to download MyDataHelps mobile application (app), and open app on participants' own phone
Not willing to abstain from alcohol for the duration of the intervention phase
Screener marked "Hold". The screener can be contacted in the future when their eligibility status changes. Mark the exclusionary criteria met based on the phone screening. Follow the guidelines below to determine when to contact the screener next.
Exclusionary Criteria Met for Hold:
* must provide value
Guidelines for Recontacting Please note an automatic email notification will be sent to the study team when it is time to pre-screen again. To calculate the tentatice recontact date, the form must saved after all information to calculate date has been added. Multiple dates will appear based on the reason for recontacting, the date to recontact for pre-screening again is the greatest date.
Re-contact pre-screener in 3-months after phone screen.Notification will send 3-months after phone screen completion date. Tentative re-contact date to assess eligibility:
Re-contact pre-screener when answer to "How long have you had problems with your sleep?" would have occured for at least 3-months.Notification will send 3-months after estimated date is entered below:Date Sleep Problem Started: Tentative re-contact date to assess eligibility:
Estimated Date:
* must provide value
Today M-D-Y
Re-contact pre-screener in 4-weeks after phone screen.Notification will send 4 weeks after phone screen completion date. Tentative re-contact date to assess eligibility:
Re-contact pre-screener in at most 30 days from phone screen or when meds would be stabilized for 30 days.Notification will send 30 days after estimated date below:Date Medication Started: Tentative re-contact date to assess eligibility:
Estimated Date:
* must provide value
Today M-D-Y
Re-contact pre-screener in at most a month after phone screen or a month after melatonin was last taken.Notification will send 30 days after estimated date below:Date Melatonin Was Last Taken: Tentative re-contact date to assess eligibility:
Estimated Date:
* must provide value
Today M-D-Y
Re-contact pre-screener in at most a month after phone screen or a month after timezone travel occured in the past or will occur in the future.Notification will send 30 days after estimated date below:Date Timezone Travel Ended: Tentative re-contact date to assess eligibility:
Date to Contact for Rescreen:(Alert/Notification is automatically created)
Today M-D-Y
Date to Contact for Rescreen:(Alert/Notification is automatically created)
Today M-D-Y
Date to Contact for Rescreen:(Alert/Notification is automatically created)
Today M-D-Y
Date to Contact for Rescreen:(Alert/Notification is automatically created)
Today M-D-Y
Date to Contact for Rescreen:(Alert/Notification is automatically created)
Today M-D-Y
Date to Contact for Rescreen:(Alert/Notification is automatically created)
Today M-D-Y
Estimated Date:
* must provide value
Today M-D-Y
First & Last Name:
* must provide value
Date of Birth:
* must provide value
M-D-Y
Email:
* must provide value
Male Female
Are you pregnant or breastfeeding?
Are you pregnant or breastfeeding?
* must provide value
Yes No
How you prefer to be contacted?
* must provide value
Phone Call Text Message Email
Would you like your information kept on file to be contacted for future research studies?
* must provide value
Yes No
Are you willing to take melatonin nightly as part of the study?
* must provide value
Yes No
Are you currently seeing a mental health professional for therapy?
* must provide value
Yes No
Are you and your therapist currently doing Cognitive Behavioral Therapy for Insomnia or Social Rhythms Therapy?
* must provide value
Yes No
Description of Therapy Type:
What about any other types of therapy where you are working on trying to alter your sleep-wake patterns?
For example, you might be scheduling and recording your bed and wake times each week, engaging in sleep restriction, or using a light box.
* must provide value
Yes No
Description of Therapy Other:
Considering only your own "feeling best" rhythm, at what time would you go to bed if you were entirely free to plan your evening?
* must provide value
8 PM - 9 PM 9 PM - 10 PM 10 PM - 11 PM 11 PM -12 AM 12 AM - 1 AM 1 AM - 2 AM 2 AM - 3 AM 3 AM - 4 AM 4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM None of the Above
Considering only your own "feeling best" rhythm, at what time would you get up if you were entirely free to plan your day?
* must provide value
4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM 10 AM - 11 AM 11 AM - 12 PM 12 PM - 1 PM 1 PM - 2 PM 2 PM - 3 PM 3 PM - 4 PM None of the Above
Are you currently working or in school?
Are you currently working or in school?
* must provide value
Yes No
Thinking only of your desired sleep schedule:
If you could fall asleep when you want or need to, what time would you choose to typically fall asleep?
If you could fall asleep when you want or need to, what time would you choose to typically fall asleep?
* must provide value
8 PM - 9 PM 9 PM - 10 PM 10 PM - 11 PM 11 PM -12 AM 12 AM - 1 AM 1 AM - 2 AM 2 AM - 3 AM 3 AM - 4 AM 4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM None of the Above
If you could wake up when you want or need to, what time would you choose to typically wake up?
If you could wake up when you want or need to, what time would you choose to typically wake up?
* must provide value
4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM 10 AM - 11 AM 11 AM - 12 PM 12 PM - 1 PM 1 PM - 2 PM 2 PM - 3 PM 3 PM - 4 PM None of the Above
On average, how many minutes does it take you to fall asleep when you have no commitments the next day?
On average, how many minutes does it take you to fall asleep when you do not have commitments the next day?
* must provide value
Example: If it takes an hour and a half then enter "90"
On average, how many minutes does it take you to fall asleep when you have commitments the next day?
On average, how many minutes does it take you to fall asleep when you have commitments the next day?
* must provide value
Example: If it takes an hour and a half then enter "90"
On average, how many hours of sleep do you get?
On average, how many hours of sleep do you get?
* must provide value
Thinking of a normal off days/weekend answer the following:
What is your bedtime?
* must provide value
8 PM - 9 PM 9 PM - 10 PM 10 PM - 11 PM 11 PM -12 AM 12 AM - 1 AM 1 AM - 2 AM 2 AM - 3 AM 3 AM - 4 AM 4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM None of the Above
What is your waketime?
* must provide value
4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM 10 AM - 11 AM 11 AM - 12 PM 12 PM - 1 PM 1 PM - 2 PM 2 PM - 3 PM 3 PM - 4 PM None of the Above
On average, how many minutes does it take you to fall asleep when you have no commitments the next day?
On average, how many minutes does it take you to fall asleep?
* must provide value
Example: If it takes an hour and a half then enter "90"
On average, how many hours of sleep do you get?
On average, how many hours of sleep do you get?
* must provide value
Thinking of a normal work/school day answer the following:
What is your bedtime?
* must provide value
8 PM - 9 PM 9 PM - 10 PM 10 PM - 11 PM 11 PM -12 AM 12 AM - 1 AM 1 AM - 2 AM 2 AM - 3 AM 3 AM - 4 AM 4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM None of the Above
What is your waketime?
* must provide value
4 AM - 5 AM 5 AM - 6 AM 6 AM - 7 AM 7 AM - 8 AM 8 AM - 9 AM 9 AM - 10 AM 10 AM - 11 AM 11 AM - 12 PM 12 PM - 1 PM 1 PM - 2 PM 2 PM - 3 PM 3 PM - 4 PM None of the Above
On average, how many minutes does it take you to fall asleep?
On average, how many minutes does it take you to fall asleep?
* must provide value
Example: If it takes an hour and a half then enter "90"
On average, how many hours of sleep do you get?
On average, how many hours of sleep do you get?
* must provide value
Do you work night shifts or rotating shifts?
Do you work night shifts or rotating shifts?
* must provide value
Yes No
If yes, what shifts do you work?
What shifts do you work?
* must provide value
How long have you had a problem with your sleep?
* must provide value
Have you ever had an overnight sleep study?
* must provide value
Yes No
If yes, why was the previous sleep study done?
If you have had a previous sleep study why as it done?
* must provide value
If yes, why was the previous sleep study done?
Have you ever been diagnosed with sleep apnea?
* must provide value
Yes No
Have you ever been diagnosed with Narcolepsy?
* must provide value
Yes No
Have you ever been diagnosed with other sleep disorders?
* must provide value
Yes No
List which sleep disorder(s) you have been diagnosed with:
List which sleep disorder(s) you have been diagnosed with:
* must provide value
Have you taken melatonin in the last month?
* must provide value
Yes No
Would you be willing to discontinue melatonin for 4 weeks before screening into the study?
Would you be willing to discontinue melatonin for 4 weeks before screening into the study?
* must provide value
Yes No
When was the last time you took melatonin?
When was the last time you took melatonin?
* must provide value
Today M-D-Y
Have you ever had an allergic or bad reaction to melatonin?
* must provide value
Yes No
What was your allergic/bad reaction to melatonin?
What was your allergic/bad reaction to melatonin?
* must provide value
Do you use any medications or home remedies to help you sleep?
* must provide value
Yes No
List the medications/home remedies you use to help you sleep:
List the medications/home remedies you use to help you sleep:
* must provide value
Have you traveled outside the eastern time zone?
* must provide value
Yes No
List the time zones you have traveled to:
List the time zones you have traveled to:
* must provide value
Central time zone Mountain time zone Pacific time zone Other time zone outside of North America
On what day did you return to the eastern time zone? *If traveled multiple times, record last return date
On what day did you return to the eastern time zone?
* must provide value
Today M-D-Y
Are you planning to travel outside the eastern time zone?
* must provide value
Yes No
List the time zones you plan to travel to:
List the time zones you plan to travel to:
* must provide value
Central time zone Mountain time zone Pacific time zone Other time zone outside of North America
On what day do you plan to return to the eastern time zone?*If traveling mulitple times, record last planned return date
On what day do you plan to return to the eastern time zone?
* must provide value
Today M-D-Y
Do you have any chronic medical illnesses?
* must provide value
Yes No
Do you have a cardiac implantable electronic device, such as defibrillator or pacemaker?
* must provide value
Yes No
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
When was the date you changed or start the medication?
Today M-D-Y
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No
Have you started or changed the dose of this medication in the past 30 days?
Yes No