Healthy Brain Study

First Name (required)

Last Name (required)

Gender (required)
 Male Female

Age (required)

Your Email (required)

Phone Number (optional)

State (required)

Have you ever been diagnosed with ADD/ADHD or any other psychiatric/ psychological disorder?
 Yes No

Do you have any parents, children, or siblings who have ever been diagnosed with ADD/ADHD or any other psychiatric/psychological disorder?
 Yes No

Do you use drugs or alcohol excessively?
 Yes No

Do you have any parents, children, or siblings who use drugs or alcohol excessively?
 Yes No

Do you have any serious problems with your memory?
 Yes No

Do you have any parents, children, or siblings who have dementia or serious memory problems?
 Yes No

Do you have any parents, children, or siblings who are mentally retarded?
 Yes No

Have you ever been diagnosed with a neurological disorder, such as epilepsy?
 Yes No

Do you have any chronic health problems?
 Yes No

Have you ever had a serious head injury (where you were knocked dizzy or unconscious)?
 Yes No

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