First Name *

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Last Name *

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Phone Number *

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Email *

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Date of Birth MM/DD/YYYY *

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Zip Code *

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What sex were you assigned at birth? *

Male

Female

Prefer not to say

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Have you been diagnosed by a doctor with Attention-deficit hyperactivity disorder (ADHD)? *
Please note, ADHD diagnosis is not required for study participation.

Yes – diagnosed by a doctor with ADHD

No

Unsure

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Have you experienced any of the following symptoms of Attention-deficit hyperactivity disorder (ADHD)? *
Select all that apply…

Unable to sit still

Fidgeting

Unable to concentrate on tasks

Short attention span/easily distracted

Forgetfulness

Excessive physical movement

Excessive talking

Impulsiveness

Feeling restless or on edge

None of the above

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Are you currently experiencing any of the following symptoms of anxiety? *
Select all that apply…

Feeling restless/ panic/ nervous/ or tense

Difficulty controlling worry

Difficulty concentrating

Uncontrollable/ obsessive thoughts

Breathing rapidly (hyperventilation)

Having an increased heart rate

Sweating

Trembling

Feeling weak or tired

Having trouble sleeping or staying asleep

Experiencing gastrointestinal (GI) complications

None of the above

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Have you been diagnosed (by a doctor) with any other medical conditions? *
(For Example: Psychosis, bipolar disorder, MDD, PTSD, dementia, OCD, personality disorder, epilepsy).
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

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Have you tried medically prescribed treatments for either your ADHD and/or Anxiety? *

Yes – I have tried treatments for my ADHD and/or Anxiety

No

Unsure

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What medically prescribed treatments have you tried for your ADHD and Anxiety? *
Please select all that apply.

Amphetamines (Adderall®/ Vyvanse®)

Methyphenidates (Ritalin®/ Concerta ®/ Aptensio®)

Atomoxetines (Strattera®)

Monoamine oxidase type B (MAO-B) inhibitors (Eldepry®/ Zelapar™/ Azilect®/ Xadago®)

SSRI and SNRI (Celexa®/ Lexapro®/ Paxil®/ Zoloft®/ Cymbalta®/ Effexor®)

Buspirone (BuSpar®)

Benzodiazepines (Ativan®/ Xanax®/ Valium®)

Other

Unsure

None of the above

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Are you taking any additional medications or treatments for your ADHD, Anxiety, or other health conditions? *
Please list them below or type ‘none’.

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Are you willing to complete a daily e-diary entry for the duration of the study? *
Please note: The total study duration is approximately 8 weeks.

Yes – willing to complete a daily e-diary entry for the duration of the study

No

Unsure

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Are you currently pregnant, breastfeeding, or planning to become pregnant? *

Yes - pregnant / breastfeeding / planning to become pregnant

No

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Which racial or ethnic group(s) do you identify with? *
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Mediterranean (Greek/Italian/Portuguese/Spanish/etc)

Another race or ethnicity

I prefer not to answer

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

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