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TEST SMA
LFFC VGA
"
*
" indicates required fields
Name
*
First
Last
Email
*
Phone
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Do you or your child spend at least 3 hours per day, 5 or more days per week, playing video games?
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Yes, Loved One
Myself
Child's Name
*
First
Last
Child's date of birth
*
Month
Day
Year
Please select all video games you or your child has played.
*
Roblox
Fortnite
Call of Duty
Overwatch
World of Warcraft
Minecraft
GTA 5
Counter-Strike
Apex Legends
Other
Do you or your child exhibit any of the following symptoms or injuries?
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ADD/ADHD
Anxiety
Orthopedic Injuries
Oppositional Defiant Disorder
Vision Injuries
Depression
Seizures
Self-Harm or Suicidal Ideation
Neurological Injuries
Other Injury
Have you or your child one received any of the following medical treatments due to playing video games?
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Counseling
Physical Therapy
Hospitalization
Doctor Visits
Gaming Addiction Program
Other Treatment
What age is the person addicted to video games currently?
*
Select
17 years of age or younger
18-21 years of age
22 years of age or older (Not Qualified)
Is the victim also addicted to Social Media?
*
Select
No
Yes, Under 18 years
Yes, Under 26 AND injury diagnosed/treated before 18
26+ OR injury diagnosed/treated at 18+
Please select all social media platforms that were regularly used
*
Instagram
TikTok
YouTube
Facebook/Meta
Snapchat
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ad_id
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