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Where are you located?
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Louisiana
Oklahoma
Texas
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First Name
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Middle Name
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Last Name
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Preferred Name
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Birthday
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MM
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DD
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YYYY
Gender
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Male
Female
Social Security Number
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Email
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Phone Number
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Phone Type
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iPhone
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Phone Carrier
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AT&T
Verizon
T-Mobile
US Cellular
Sprint
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Cricket
TracFone
Google Fi
Other
Street Address
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City
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State
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Zip Code
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Insurance Provider (for prescription purposes only), if you do not have insurance, please answer "none".
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Employment Status
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Full time
Part time
Self-Employed
Unemployed
Student
Employer
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Emergency Contact
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Relationship
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Emergency Contact Phone Number
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May we discuss your medical condition and treatment plan with someone else, like a friend or family member?
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Yes
No
If yes, please give us the name of the person(s) that we are allowed to talk to.
(If no, please put none)
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Have you had any of the following symptoms? Select all that apply.
*
Weight Gain
Weight Loss
Decreased Appetite
Problems Staying Awake
Problems Falling Asleep
Heart Palpitations
High Blood Pressure
Chest Pains
Chest Tightness
Shortness of Breath
Frequent Headaches
Motor Tics
Verbal Tics
Anxious
Rigid / Inflexible
Depression
Paranoid
Racing Thoughts
Obsessive Compulsive Behavior
Over Sensitive / Sensory Issues - Hates Tags - Loud Noises - Certain Food Textures
Aggression
Frequent Anger
Substance Abuse
None of the Above
Required
Medical Allergies
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Your answer
Current Medications
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Your answer
ADHD Medications taken in the past two years
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Your answer
Family History. Select all that apply.
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Addiction / Substance Abuse
Heart disease less than 50
Hypertension
Headaches / Migraines
Tics / Tourettes
Depression
Bipolar Disorder
Obsessive Compulsive Disorder
Anxiety
Panic Attacks
Schizophrenia / Psychosis
ADHD
Not Applicable
Required
Sleeping History. Select all that apply.
*
Trouble falling asleep
Trouble Staying Awake
Sleep Walking
Sleep Talking
Nightmares / Terrors
Gone 24 hours without sleep
Do you frequently sleep after work/school
Do you frequently feel tired or fall asleep throughout the day
None of the Above
Required
Have you ever been formally diagnosed with ADHD?
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Yes
No
If yes - when were you diagnosed and by whom?
(If no, please put N/A)
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Do you have documentation of previous testing?
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Yes
No
Never been formally diagnosed
Are you currently under a provider's care for ADHD?
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Yes
No
Why are you changing ADHD providers?
Your answer
Number of children?
Your answer
What is your highest level of education?
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Are you currently in college/grad school?
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Yes
No
What kind of work do you do?
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Do you exercise regularly?
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Yes
No
How would you describe your general stress level?
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Your answer
What is your driving history? Select all that apply.
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None
Violations
Accidents
License Suspended or Revoked
Required
How many caffeinated beverages do you consume per day?
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None
1 to 2
3 to 5
6 or More
Do you use alcohol?
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Yes
No
If yes - how many drinks per week?
(If no, put 0)
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Do you use tobacco or vape?
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Yes
No
Do you use marijuana?
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Yes
No
Have you ever used or are you currently using illicit drugs?
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Yes
No
Do you participate in any type of rehab program or substance abuse counseling?
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Yes
No
Have you ever had any legal issues?
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Yes
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Did a friend or family member refer you to our clinic? If so, what is their name?
Your answer
Have you read the
HIPAA Privacy Notice
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