sheldon.health - ADHD & Neurodivergent Wellbeing Tracking

Patient details - this information will be confidential

Contact Information

Patient Number *

Last Name *

Email *

Phone

State *

Postal Code *

Question 1:

Question 2:

Sex *

Male

Female

Other

Question 3:

Question 4:

Relationship Status *

Single

Short term relationship (less than 1 year)

Long term relationship (more than 1 year)

Question 5:

Question 6:

Alcohol consumption per week *

Less than 3 standard drinks (SD) per week

3-10 SD per week

10-15 SD per week

16 plus

Question 7:

Time frame receiving a diagnosis *

Within the last 6 months

Within 6months to 12 months

Last 5 years

Greater than five years

Question 8:

Other diagnosed psychiatric difficulties

Question 9:

Experiences relating to any of the following

Problems with social interactions, being understood or knowing the right thing to say

Awareness of peoples body language in social settings

Difficulties adjusting to changes in routines

Marked sensitivities to sounds, touch and smell

Question 10:

Did your ADHD symptoms commence before the age of 12 years? *

Yes

No

I consent to my information being used to complete this ADHD patient survey and assessment. *

Patient Details