Your first name:* must provide value
Your last name:* must provide value
Your child's first name:* must provide value
Your child's last name: * must provide value
Your phone number:* must provide value
Your email address:* must provide value
Your child's date of birth (m-d-y):* must provide value
Today M-D-Y
Your child's gender: * must provide value
Female
Male
Other
Does your child have a diagnosis of ADHD?* must provide value
Yes
No
If your child has a diagnosis of ADHD, please indicate the approximate date of diagnosis:* must provide value
Has your child ever been diagnosed with any of the following psychiatric conditions?* must provide value
Yes
No
Please describe any additional psychiatric diagnoses your child has received (if checked "yes" to the item above): * must provide value
Does your child have any other behavioral or medical diagnoses?* must provide value
Yes
No
Please describe any additional diagnoses your child has: * must provide value
How did you hear about our study?
What prompted you to contact us?
What is your child's approximate weight?* must provide value
What is your child's approximate height?* must provide value
Does your child speak and understand English?* must provide value
Yes
No
Has your child had any of the following medical problems?* must provide value
high blood pressure
kidney/urinary tract problems
breathing problems (ex. asthma)
stomach/bowel problems
hypo/hyperactive thyroid
neurological problems (ex. seizures)
diabetes
concussions
migraines
loss of consciousness
hormone replacement
none of the above
Please describe any other medical problems your child has experienced:
Has your child had any surgery of any sort?* must provide value
Yes
No
If your child has had surgery, please describe procedure(s) and date(s).* must provide value
Has your child ever been hospitalized?* must provide value
Yes
No
If your child has been hospitalized, please describe reason(s) and date(s).* must provide value
Has your child had any neurological problems?* must provide value
Yes
No
If your child has experienced neurological problems, please describe the problem(s) and date(s).* must provide value
Does your child have a genetic condition?* must provide value
Yes
No
If your child has a genetic condition, please describe.* must provide value
Were there any difficulties during pregnancy or delivery for your child? * must provide value
Yes
No
Please describe any pregnancy or delivery difficulties.* must provide value
Was your child born prematurely?* must provide value
Yes
No
How many weeks gestation was your child at birth?* must provide value
How much did your child weigh at birth?* must provide value
Did you have any concerns about your child's development as an infant or young child?* must provide value
Yes
No
Please describe.* must provide value
Please describe any medications and dietary supplements your child has taken over the past 12 months. Please include dates, dosage, and frequency.* must provide value
Please describe any allergies your child has. * must provide value
Elaborate if you answered yes to any of the above in the MRI screening section
Your Name* must provide value
Your Sex* must provide value
Male Female
Child's Name* must provide value
Relationship to Child* must provide value
Today's Date* must provide value
Today M-D-Y
Age at assessment View equation
@HIDDEN
Child Sex View equation
@HIDDEN
Is there anything else that you'd like me to know about your child and his/her potential participation in our study(ies)?
Is it ok to contact you about your child's eligibility for this study?* must provide value
Yes
No
Is it ok to contact you about your child's eligibility for other studies?* must provide value
Yes
No
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