Tourette Syndrome 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

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” or similar words. Message and data rates may apply. By clicking ”Yes”, you also agree to our SMS Terms. *

yes no

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code *

Are you Male or Female? *

Male

Female

Prefer not to say

Have you ever been diagnosed with Tourette Syndrome by a doctor at any point in your life? *

Yes - diagnosed with Tourette Syndrome

Unsure

Do you experience motor and vocal tics? *
Please note: Tics are abrupt sounds or repetitive movements that cannot be controlled.

Yes - motor tics and vocal tics

Yes - only motor tics

Yes - only vocal tics

Have you ever received treatment for your Tourette syndrome, and/or are you currently seeking a new treatment? *

Yes – have tried treatment and/or seeking new treatment

No – never tried treatment

Unsure

What treatments have you had for Tourette syndrome? *

Neurostimulation

Deep Brain Stimulation

Other

None

Unsure

Are you taking any medications or treatments for your Tourette syndrome or other health conditions? *
Please list them below or type ‘none’.

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For Example: Traumatic brain injury, stroke, uncontrolled seizure disorder, severe anxiety, bipolar disorder, schizophrenia, Huntington's Disease, Parkinson's disease)
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

Please, select your height from the dropdown below. *

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

Are you currently pregnant or breastfeeding? *

Yes No

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

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.