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)?
Yes
No
6. Other than your child, do you have any immediate relatives with Autism or related conditions such as
Asperger’s Syndrome?
Yes
No
7. What is the child's ethnicity?
Caucasian
African
Asian
American Indian
Other
8. If your child was diagnosed with Autism, how old were they when diagnosed?
Not diagnosed with Autism
6 – 12 months
1 – 2 years
2 – 3 years
Older than 3 years
Before Birth:
9. Did the mother smoke directly before or during pregnancy?
Yes
No
10. Did the father smoke directly before conception?
Yes
No
11. Did the mother contract the Rubella virus during pregnancy?
Yes
No
12. During pregnancy, did the mother take any drugs for epilepsy, bipolar disorder or to prevent migraine headaches?
Yes
No
13. During pregnancy, were any of the drugs Thalidomine, Immunaprim, Talidex, Talizer or Thalomid taken by the mother?
Yes
No
14. During pregnancy, did the mother take Misoprostol, other than to induce labor?
Yes
No
15. During pregnancy, did the mother consume any grain alcohol (ethanol)?
Yes
No
16. Did the mother handle herbicides at any point during pregnancy?
Yes
No
17. Did the mother take vitamins during pregnancy?
Yes
No
18. Did the mother take birth control pills directly before getting pregnant?
Yes
No
19. On average, many hours sleep per night did the mother get while pregnant?
<4
4-6
6-8
8-10
>10
20. During pregnancy, what percentage of meals were consumed by the mother from a fast-food restaurant?
0 – 25 %
25 – 50 %
50 – 75 %
75 – 100 %
21. How far did the mother live from the nearest freeway while pregnant?
< 100 ft (< 30 m)
100 - 1000 ft (30 to 300 m)
1000 ft – 1 mile (300m – 1.6 km)
> 1 mile (> 1.6 km)
22. During the pregnancy, our residence was sprayed with a pesticide how many times per month?
Never
1 – 2
3 – 4
I don’t know
23. Did the mother take any antibiotics while pregnant?
Yes
No
24. Were there large high-tension power lines directly adjacent to the mother’s residence, while pregnant?
Yes
No
25. Were fabric softeners used on clothing and/or bedding while the mother was pregnant?
Yes
No
26. On average, how much cow’s milk was consumed by the mother per week while pregnant?
None
½ gallon (~2 liters)
1 gallon (~4 liters)
> 1 gallon (> 4 liters)
27. How many cups of coffee per day, on average, did the mother drink while pregnant?
None
1 – 2
3 – 4
> 4
28. During pregnancy, did the mother drink diet soft drinks on a regular basis?
Yes
No
29. While pregnant, did the mother drink bottled water on a regular basis?
Yes
No
30. Did the mother cook with non-stick pans coated with plastic (such as Teflon) while pregnant?
Yes
No
31. While pregnant, the mother’s residence had water supplied from:
City or municipal water
A community well
Private well
I don’t know
32. During pregnancy, the mother mainly used which product regularly?
Antiperspirant
Deodorant
None of the above
Other
33. How many alcoholic drinks did the mother consume per week while pregnant?
None
1 – 4
5 – 10
> 10
34. During pregnancy, on average, the mother smoked how many cigarettes per day?
None
1 – 2
3 – 10
> 10
35. During pregnancy, the mother was taking which of the following?
Antidepressant
Pain killers
Muscle relaxers
Diet pills
None of the above
36. During pregnancy, the mother painted or had painted her toes or fingernails with nail polish?
Yes
No
37. During pregnancy, the mother cleaned the bathrooms with:
Soap
Bleach
Bathroom / tile cleaner
None of the above
38. During pregnancy, the mother used body lotion, oil or cream on her skin?
Yes
No
39. The mother ate seafood how many times per week while pregnant?
0
1 – 2
3 – 5
> 5
40. During pregnancy, did the mother worked as a cashier, waitress or any job that required handling of receipts printed on thermal paper?
Yes
No
After Birth:
41 What was the baby’s birth weight? (lb|oz)
UNK
0 lb 1 lb 2 lb 3 lb 4 lb 5 lb 6 lb 7 lb 8 lb 9 lb 10 lb 11 lb 12 lb 13 lb 14 lb 15 lb
UNK
0 oz 1 oz 2 oz 3 oz 4 oz 5 oz 6 oz 7 oz 8 oz 9 oz 10 oz 11 oz 12 oz 13 oz 14 oz 15 oz 16 oz
42. The baby breast fed for how many months?
Never
1 – 3
3 – 6
7 – 12
>12
43. What formula was used to feed the baby?
None
Ready-to-use formula (pre-mixed)
Mixed with tap water
Mixed with nursery water
Mixed with bottled/packaged water
44. Formula was heated by:
Bottle warmer
Microwaving the Bottle
On the stove in a pot
On the stove heating water/bottle
Not heated
45. Generally, what type of formula did the baby consume?
Cow’s milk based
Lactose sensitive
Soy-based
Did not consume formula
46. Most of the time, the baby fed from bottles made from:
Plastic
Glass
Metal
Did not bottle feed
47. What percentage of the time did the baby use a pacifier before the age of one?
0 – 25 %
25 – 50 %
50 – 75 %
75 – 100 %
48. Before the age of one, what type of residence did the baby live?
Single-family home
Condo or townhome
Apartment
Other
49. Did the parent(s) of the baby own this residence?
Yes
No
50. Were the carpets of this residence cleaned while the baby was younger than one?
Yes
No
51. Before the age of one, the baby was dressed in clothing made mainly of:
Cotton
Polyester
Polyester-cotton blend
Other
52. During the first year of life, the baby ate food packaged mainly in:
Glass jars
Plastic pouches or containers
A combination of glass and plastic
Food was generally home made
53. For the first year, what type of diapers were used?
Cotton
Disposable
Other
No diapers used
54. For the first year, the baby lived in a residence with floors made mainly of:
Tile
Vinyl
Carpet
Wood
Other
55. Genrally, the furniture in the baby's room was made from:
Solid wood
Veneered Pressboard
Plastic
I don’t know
56. Before the age of one, most of my child’s toys were made from:
Metal
Plastic
Fabric
I don’t know
57. At the time of my child’s first birthday, he/she watched television an average of how many hours per day:
0 – 1
1 – 2
2 – 4
> 4
58. My child’s sheets were mainly made of:
Cotton
Polyester
Polyester-cotton blend
I don’t know
Other
59. Before my baby’s first year, other than breast milk or formula, he/she mainly drank:
Tap water
Bottled water
Fruit juice
Other
60. During the first year of life, my baby’s bottles were cleaned mainly by:
Hand Washing
Dishwasher
61. When did your child receive his/her MMR (measles, mumps and rubella) vaccine?
Never
< 1 year old
Around 1 year old
> 1 year old
62. After your child received the MMR vaccine, he/she was given what medication to alleviate the pain?
No vaccine given
Aspirin
Tylenol (or any branded Acetaminophen)
Motrin (or any branded Ibuprofen)
No pain reliever given
63. During your child’s first year, did you own a pet cat?
Yes
No
64. During your child’s first year, did you own a pet dog?
Yes
No
65. Before the age of one, my child was outside how many days per week on average?
0
1 – 2
3 – 5
> 5
66. When my child was younger than one, he was raised in a city with what population?
< 10,000
10,001 – 100,000
100,001 – 1,000,000
> 1,000,000
67. When my child was younger than one, sometimes carpet deodorizer was used?
Yes
No
68. Before the age of one, my child’s family had a pet
Hamster
Turtle
Guinea pig
Mouse
None of the above
69. To treat my child for teething pains, we would give him/her mainly:
Aspirin
Tylenol (or any branded Acetaminophen)
Motrin (or any branded Ibuprofen)
Other
70. My baby was given Orajel (or equivalent) for teething pains?
Yes
No
71. My child generally used pacifiers made from:
Silicone
Latex rubber
Soft plastic
Did not use a pacifier
I do not know
72. When my child was younger than one, the countertops were cleaned mainly with:
Soap and water
Bleach and water
Commercial kitchen cleaner
Other
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