Family exposure questionnaire

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 autismhormoneproject@gmail.com. We will keep your identity absolutely confidential.  Thank you!
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Transgenerational Prenatal Exposures Questionnaire

This 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!
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Name:

Email:

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.

3. Are these disabilities idiopathic (cause unknown), or do you know the cause (ie, a genetic syndrome, prematurity, a complication during birth)?

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?

6. 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 life?

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 autismhormoneproject@gmail.com.