Autism Spectrum Disorder Survey

Please only take this survey if your child (may now be older or grown):

• Is older than 5 months and not diagnosed with Autism Spectrum Disorder (ASD)

- OR -

• Has been diagnosed with Autism Spectrum Disorder
 

Autism Diagnosis:

1. To ensure unique survey data, please provide your email address: (example@domain.com)
(We will not send you spam.)

2. What is your child's birthdate? (mm/dd/yyyy)

3. What is your child's father’s birthdate? (mm/dd/yyyy)

4. What is your child's mother’s birthdate? (mm/dd/yyyy)

5. Was your child diagnosed with Autistic Spectrum Disorder (Autism)?

6. Other than your child, do you have any immediate relatives with Autism or related conditions such as Asperger’s Syndrome?

7. What is the child's ethnicity?

8. If your child was diagnosed with Autism, how old were they when diagnosed?

Before Birth:

9. Did the mother smoke directly before or during pregnancy?

10. Did the father smoke directly before conception?

11. Did the mother contract the Rubella virus during pregnancy?

12. During pregnancy, did the mother take any drugs for epilepsy, bipolar disorder or to prevent migraine headaches?

13. During pregnancy, were any of the drugs Thalidomine, Immunaprim, Talidex, Talizer or Thalomid taken by the mother?

14. During pregnancy, did the mother take Misoprostol, other than to induce labor?

15. During pregnancy, did the mother consume any grain alcohol (ethanol)?

16. Did the mother handle herbicides at any point during pregnancy?

17. Did the mother take vitamins during pregnancy?

18. Did the mother take birth control pills directly before getting pregnant?

19. On average, many hours sleep per night did the mother get while pregnant?

20. During pregnancy, what percentage of meals were consumed by the mother from a fast-food restaurant?

21. How far did the mother live from the nearest freeway while pregnant?

22. During the pregnancy, our residence was sprayed with a pesticide how many times per month?

23. Did the mother take any antibiotics while pregnant?

24. Were there large high-tension power lines directly adjacent to the mother’s residence, while pregnant?

25. Were fabric softeners used on clothing and/or bedding while the mother was pregnant?

26. On average, how much cow’s milk was consumed by the mother per week while pregnant?

27. How many cups of coffee per day, on average, did the mother drink while pregnant?

28. During pregnancy, did the mother drink diet soft drinks on a regular basis?

29. While pregnant, did the mother drink bottled water on a regular basis?

30. Did the mother cook with non-stick pans coated with plastic (such as Teflon) while pregnant?

31. While pregnant, the mother’s residence had water supplied from:

32. During pregnancy, the mother mainly used which product regularly?

33. How many alcoholic drinks did the mother consume per week while pregnant?

34. During pregnancy, on average, the mother smoked how many cigarettes per day?

35. During pregnancy, the mother was taking which of the following?

36. During pregnancy, the mother painted or had painted her toes or fingernails with nail polish?

37. During pregnancy, the mother cleaned the bathrooms with:

38. During pregnancy, the mother used body lotion, oil or cream on her skin?

39. The mother ate seafood how many times per week while pregnant?

40. During pregnancy, did the mother worked as a cashier, waitress or any job that required handling of receipts printed on thermal paper?

After Birth:

41 What was the baby’s birth weight? (lb|oz)

42. The baby breast fed for how many months?

43. What formula was used to feed the baby?

44. Formula was heated by:

45. Generally, what type of formula did the baby consume?

46. Most of the time, the baby fed from bottles made from:

47. What percentage of the time did the baby use a pacifier before the age of one?

48. Before the age of one, what type of residence did the baby live?

49. Did the parent(s) of the baby own this residence?

50. Were the carpets of this residence cleaned while the baby was younger than one?

51. Before the age of one, the baby was dressed in clothing made mainly of:

52. During the first year of life, the baby ate food packaged mainly in:

53. For the first year, what type of diapers were used?

54. For the first year, the baby lived in a residence with floors made mainly of:

55. Genrally, the furniture in the baby's room was made from:

56. Before the age of one, most of my child’s toys were made from:

57. At the time of my child’s first birthday, he/she watched television an average of how many hours per day:

58. My child’s sheets were mainly made of:

59. Before my baby’s first year, other than breast milk or formula, he/she mainly drank:

60. During the first year of life, my baby’s bottles were cleaned mainly by:

61. When did your child receive his/her MMR (measles, mumps and rubella) vaccine?

62. After your child received the MMR vaccine, he/she was given what medication to alleviate the pain?

63. During your child’s first year, did you own a pet cat?

64. During your child’s first year, did you own a pet dog?

65. Before the age of one, my child was outside how many days per week on average?

66. When my child was younger than one, he was raised in a city with what population?

67. When my child was younger than one, sometimes carpet deodorizer was used?

68. Before the age of one, my child’s family had a pet

69. To treat my child for teething pains, we would give him/her mainly:

70. My baby was given Orajel (or equivalent) for teething pains?

71. My child generally used pacifiers made from:

72. When my child was younger than one, the countertops were cleaned mainly with: