The Autism Survey.com

Autism Spectrum Disorder Survey

Please take this survey to help us understand environmental factors of the Autism Spectrum Disorder. Information obtained from parents of both Autistic and non-Autistic kids is needed to solve the riddle of causality.


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. 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?

Caucasion
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)



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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