To help our efforts, please consider responding to the brief questionnaire below. Simply cut and paste it into your email and send your answers to firstname.lastname@example.org. We will keep your identity absolutely confidential. Thank you!
Transgenerational Prenatal Exposures Questionnaire
questionnaire is for parents of children with idiopathic (cause
unknown) neurodevelopmental disorders such as autism, ADD, ADHD,
Aspergers, PDD, OCD, Tourettes, emotional disturbance, learning
disabilities and/or sensory processing disorders. It will only take a
few minutes of your time. Your information is for screening purposes only (we will follow up by email to gather further details) and will be kept strictly confidential. Thank you!
1. How many children do you have, what are their ages and genders?
2. Do any of them have physical or neurodevelopmental disabilities? If yes, please describe.
Are these disabilities idiopathic (cause unknown), or do you know the
cause (ie, a genetic syndrome, prematurity, a complication during
4. In what year and where was the mother of the disabled child(ren) born?
5. In what year and where was the father of the disabled child(ren) born?
Do you know whether either parent (ie, you or your spouse) was
exposed, in utero, to pharmaceutical drugs? In other words, do you
know if either grandmother of the child(ren) was prescribed
pharmaceuticals for the prevention of miscarriage, to prevent preterm
birth, to address complications, to alleviate morning sickness, or for
any other reason? [Note: you will probably have to ask the
grandmothers.] Do you know of other possible exposures, such as
smoking, street drugs or alcohol?
7. If you cannot find
that information first-hand, do you have any reason to believe either
grandmother had suffered several prior miscarriages before conceiving
you or the other parent?
8. What other exposures may
have you, your spouse, or either of your parents experienced? Agent
Orange? Radiation? Herbicides? Pesticides like DDT? During what time of
9. Did the mother of the affected child(ren)
use any drugs or interventions during the pregnancy, such as
antidepressant drugs, or assisted reproduction like IVF? Any other
drugs or pharmaceuticals?
10. Did the mother of the affected child(ren) have PCOS or gestational diabetes?
Thank you for your time. Please email your confidential responses to email@example.com.