Autism SURVEY

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Autism and Autistic Spectrum Disorders: Survey

This form is available in several languages. Please, click on the flag to bring up the appropriate survey form.

If you have a child who has been diagnosed with Autism or Autistic Spectrum Disorder, PLEASE fill out the short survey below. Survey is anonymous and its purpose is to define certain factors that may contribute to the development of this disorder.

THANK YOU VERY MUCH, Miroslav Kovacevic, MD FAAP

Survey Form A103

Questions marked with (*) must be answered. If there are no relevant information available, write "none" into the field.

Patient's personal data:

Current age

Month of birth

Sex

Patient is

Patient is the child.

What is patient's ethnical background?*

Description of patient's initial symptoms:

At what age was the first symptom noticed?*

What specifically was the FIRST symptom or concern?*

The onset of patient's symptoms can be described as...*?

Date of the first visit to the doctor for these symptoms:

Date when definite diagnosis was established:

Within 4 WEEKS before the symptom appearance patient...

Within 4 WEEKS before the symptom appearance was anyone sick in the household?

Within 6 WEEKS before the symptom appearance did patient receive any immunizations?

YES

If "YES" what was it?

Within 6 WEEKS before the symptom appearance did anyone else in the household receive any immunizations?

YES

If "YES" what was it?

During the FIRST 15 months of life had this child ever been given Tylenol (acetaminophen) for reasons OTHER than fever >101^o F?

YES

Has this child exhibited UNUSUAL SENSITIVITY to...

Light?

Sounds?

Touch?

Exposure to hot or cold?

Particular tastes?

Has child EVER had unusually large pupils?

Yes

Has this child exhibited UNUSUAL CRAVING for sugar or sweets?

Yes

Has this child ever had PROLONGED (longer than 4 weeks) periods of any of the following:

Diarrhea?

Constipation?

Poor sleeping habits (wakefullness, nightmares)?

Did this child ever had a SEIZURE?Yes

Age of the FIRST seizure?

List all therapies that patient has received to date (medications, speech therapy, occupational therapy, physical therapy, etc.)*:

Has patient received any treatment that has NOT been ordered by the doctor?

Please list all alternative treatments that child has received*:

History of mother's pregnancy with this child, birth and early development of this child:

Mother's age at birth of this child:

Mother's education level:

Mother's profession:

Father's age at birth of this child:

Father's education level:

Father's profession:

What was the duration of pregnancy with this child?

Frequency of fish consumption by mother during this pregnancy:

During this pregnancy did this mother take any pain medications, i.e., Tylenol, Advil, etc.?

YES

During this pregnancy did mother receive any Iron supplementation?

YES

During this pregnancy did anyone in the household receive any viral immunizations?

Were there any pets in the household before or during this pregnancy?

YES

Specify:

Did mother have any contact with horses before or during this pregnancy?

YES

Specify:

Was pregnancy with this patient normal?

YES

Was delivery of this patient normal?

YES

Were there any problems with this patient at birth?

YES

Mother's pregnancy complications with this child:

Diabetes or sugar in urine?

Elevated blood pressure

Protein in urine?

Kidney or urinary tract infection?

Venereal diseases including Herpes?

Other infections?

Bleeding during pregnancy?

List any other illnesses (including minor colds) that mother might have had during this pregnancy?*

List any medications that mother might have taken during this pregnancy, including cold remedies, Tylenol, herbal remedies, etc.?*

Complications during delivery/birth of this child?

Cesarean section delivery?

Vacuum assisted delivery?

Placental abruption?

Birth weight

APGARS:1 min. 5 min.

Were there any medical problems with this patient during the newborn period?

Neonatal jaundice?

Neonatal infection?

Neonatal respiratory problems?

Prolonged hospitalization?

Any other problems? Please describe*:

Was this child breast fed?

YES

For how long

If formula was offered specify what kind of formula:

At what age were solids first introduced?

Did child receive ANY iron-fortified foods BEFORE 6 months of age (i.e. cereal)?

YES

Other IRON supplementation?

Child was independently sitting by...

Child was independently walking by...

Child spoke first words at...

Child's current physical development is...

Child's current growth is...

Child's current speech development is...

Please use this space to describe any other important EVENT, OCCURRENCE, or CHARACTERISTIC that in your personal opinion could have in any way contributed to child's condition*:

THANK YOU VERY MUCH FOR YOUR TIME AND EFFORT!

Write in your e-mail address (OPTIONAL)

e-mail

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