For Patients Child & Adolescent new patient packet Click for more information Adult new patient packet Click for more information Missionary Packet Click for more information Research Study To be considered for a research study, please complete the following information: Name* First Last ** *When is the best time to contact you?8am - 10am10am - 12pm12pm - 2pm2pm - 4pm*DiagnosisAdult DepressionChild/Adolescent DepressionTourette's DisorderAnxietyAdult ADHDChild/Adolescent ADHDSchizophreniaPostpartum DepressionBinge Eating DisorderAutismBipolar Disorder*Are you currently taking medication for depression?Yes, I'm currently taking medication for depressionNo, I'm NOT currently taking medication for depression*How old is your child?4-11 years old12-17 years old*How old is your child?6-11 years old12-17 years old*Is your child currently taking medication for ADHD?Yes, I'm my child is currently taking medication for ADHDNo, my child is NOT currently taking medication for ADHD*Does your child show signs of aggression?Yes, I would consider my child aggressiveNo, I would NOT consider my child aggressive*Does your child currently show signs of depression?Yes, I would consider my child depressedNo, I would NOT consider my child depressed*Does your child have a biological parent/sibling diagnosed with Bipolar disorder?Yes, my child has a biological parent or sibling diagnosed with Bipolar disorderNo, my child does NOT have a biological parent/sibling diagnosed with Bipolar disorder*Have you had at least 1 manic episode in the past?Yes, I've had at least 1 manic episode in my pastNo, I've never had a manic episode*If you qualify, are you willing to be hospitalized for a part of the study?Yes, I'm okay with being hospitalized for a part of this studyNo, I do not want to be in the hospital at all, even for a short time*Have you EVER been diagnosed with Schizophrenia, Schizoaffective Disorder, ADHD or a personality disorder?Yes, I've been diagnosed with one of the aboveNo, I have never been diagnosed with one of those*Have you received ECT treatment within the last 2 months?Yes, I have received ECT within the last 2 monthsNo, I have NOT received ECT within the last 2 months*Have you felt "manic" for the last 4 weeks?Yes, I have felt manic for at least the last 4 weeksNo, I have felt manic for less than 4 weeks*How is your depression since being on the antidepressant medication?Great! I don't feel depressed at allImproved but still not where I want to beI can't tell if the medicine makes a difference or notThings are a little worse since I've been on the medicineHorrible! My depression is significantly worse*Are you currently taking MORE THAN ONE medication for depression?Yes, I'm taking more than 1 medication for my depressionNo, I'm only taking one medication for my depression*Have you ever been diagnosed with ADHD?Yes, I've been diagnosed with ADHD sometime in my lifeNo, I've never been diagnosed with ADHD*Are you between 18-65?Yes, I'm between 18-65 years oldNo, I'm 66 or older*Are you between 18-55?Yes, I'm between 18-55 years oldNo, I'm 56 or older*What medications are you currently taking?*Please list any other medications your child takes*Please list any other medications your child takes*Please list other diagnosis or health conditions your child has*Please list other diagnosis or health conditions your child has*Are you taking any medications or supplements to help you lose weight or have you had any weight loss surgeries?*What is your current height and weight?*On average, how many binges do you have per week?*Do you have any medical conditions? If so, what?*Do you have any medical conditions? If so, what?