ADHD Assessment Questionnaire

Aspen Health and Wellness is conducting free ADHD Assessments for individuals 6 through 55 years of age. This assessment will help us identify potential individuals to participate in a clinical research study of an investigational drug to improve inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

To participate in this ADHD Assessment, please fill out the form below and an Aspen Health and Wellness representative will contact you shortly.

ADHD Assessment Questionnaire

First Name (required)
Last Name (required)
Email Address
Male or Female?
Address/Street Name
City
State
Zip
Date of Birth? (MM-DD-YYYY)(required)
Primary Phone? (required)

Other Phone?
Best Time to Call:
Please list the name, dose, and frequency of any medications you are currently taking:

Type the following in the input box