SURVEY
Please take the time to fill out this survey. You may check all appropriate boxes relevant to your situation. Please answer all questions. If a question does not pertain to you, please write N/A on the line provided in front of the number of the question. Please do NOT write your name or any other personal information on the questionnaire as this is meant to be an anonymous survey. Thank you...any personal information I do happen to come across I will delete immediately! Much appreciation!
___1. Are you male or female
___2. What age group do you fall under?
18 - 25 41 - 45
26 - 30 46 - 50
31 - 35 51 +
36 - 40
___3. What ethnicity best describes you?
Caucasian Hawaiian Native or Pacific Islander
African American Latin American or other Hispanic
Asian American Other
American Indian and Alaska Native persons
___4. What is the highest level of education you have completed?
High School Graduate level
College Doctorate
Other
___5. What income level best describes your household?
under ,000 35,000 - 49,000
,000 - ,999 50,000 and above
___6. What relationship is the ADHD/ADD diagnosed patient to you?
son niece
daughter nephew
husband grandson
wife granddaughter
partner I am the patient
other, please indicate relationship_________________________
___7. Please write down any and all treatment methods you are aware of. And circle those which you have pursued.
________________________ ________________________
________________________ ________________________
________________________ ________________________
________________________ ________________________
___8. What is your preferred method of treatment?
___9. Who is paying for the treatment?
you government
private aid other, please indicate who/what ____________________
___10. Are you receiving any public aid?
yes no
If yes, what is the name of the company?____________________________
___11. Please name which treatment method(s) the patient is currently undergoing?
________________________ ________________________
________________________ ________________________
___12. Are you in a decision making position in terms of the treatment method to pursue for the patient?
yes no
___13. Are you the patient’s primary care-taker?
yes no
I am the patient
____14. What State do you live in?
Once again, thank you so much for taking the time and filling out this survey to the best of your knowledge, all content will be kept confidential and will not be used for anything more than research reference material.