Putnam Valley Pediatrics       

 

     ADHD On-Line Patient Followup Questionnaire

 

                             (For Currently Registered Participants Only)

( * = Required Field)

1. What is your first name ?   *   

        1a. For confirmation, what is your date of birth (mm/dd/yy) ?  * 

2. What medicine are you currently taking ?  *             

        2a. Are you having problems with the medicine (Yes/No)?  *     

        2b. Do you think it is helping you ? *                   

3. Does it work all day, or does it "wear off"--and if it does, around what time ?

                                

4. Do you feel more successful in school ?            

5. Do you have any concerns or questions ? 

             

13. E-Mail address to reach you:

 

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