Adult ADHD Treatment

Fields marked with an * are required.

First Name *

Last Name *

Phone Number *

Date of Birth MM/DD/YYYY *

ZIP or Postal Code *

Are you Male or Female?

Have you been diagnosed by a doctor with ADHD? *

Select a response that best describes how you have felt and conducted yourself over the past 6 months.
Options: NEVER, RARELY,SOMETIMES,OFTEN, or VERY OFTEN.

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? *

How often do you have difficulty getting things in order when you have to do a task that requires organization? *

How often do you have problems remembering appointments or obligations? *

When you have a task that requires a lot of thought, how often do you avoid or delay getting started? *

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? *

How often do you feel overly active and compelled to do things, like you were driven by a motor? *

Do you have access to the internet? *

Will you be able to play a video game on an iPad for at least 25 minutes a day as part of this study? * (IPAD will be provided)

Have you been diagnosed with color blindness? *

Have you been diagnosed (by a doctor) with any of the following: Seizures, Significant tics, Epilepsy, or Tourette syndrome? *

Do you have or have you had recently (within the past year) a substance use disorder? *

Are you currently or recently have been (within the past 3 months) a heavy smoker (equal to or greater than a pack of cigarettes a day)? *

Are you currently participating in a clinical trial for an investigational drug or device? *

Would you like to be contacted about taking part in a Clinical Trial that you may qualify for? *

Yes

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

The information you are providing here will only be used to match you or a loved one to a clinical research study in the potential participant’s area and contact you to see if you or a loved one would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to autocruitment.com, or if you would like to make any changes, please contact us at info@autocruitment.com.