Questionnaire - Please Forward

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Subj: Questionnaire - Please Forward

Date: 8/23/00 10:22:33 AM Eastern Daylight Time

From: <A HREF= " mailto:END AUTISM " >END AUTISM</A>

<A HREF= " mailto:NANCALE " >NANCALE</A>

is a high-school student in NY who is studying the onset of autism

in children. She has been studying different aspects of autism for a few

years now. She is in the final stages of a major project. She needs about

150 more responses from people with neurotypical children and no incidence of

autism in their families for her control group.

If you could pass this questionnaire on to some of your friends with

neurotypical children and ask them to take a few moments to fill it out and re

turn it to DGolden182@..., we would greatly appreciate it.

hopes to go into research one day for autism and we want to help get

dedicated people like her there to help our kids!

Thanks so much!

Reynolds

Unlocking Autism

General Information

1.) Your state_____

2.) Child's age____

3.) Child's birthdate_________

4.) Child's gender____

5.) What is the child's birth order in the family? (1st, 2nd, 3rd...)______

6.) Is child a twin or triplet? No___ Twin___ Triplet___

Birth Problems

7.) Was child premature? Yes___ No___

If so, how many weeks?_____

8.) Was child late? Yes___ No___

If so, how many weeks?_____

9.) Was child delivered through induced labor? Yes___ No___

10.) Was there post trauma or birth trauma? No___ Post___ Birth___

11.) Was child jaundiced? Yes___ No___

12.) Did you take any prescription or over the counter medications during

pregnancy? Yes___ No___

Vaccinations

13.) At what age did child receive MMR?____

14.) Did child take antibiotics at a young age? (0-2 yrs) Yes___ No___

15.) Has child received the HebB vaccine? Yes___ No___

If so, was it given in the hospital? Yes___ No___

Further Studies

16.) Would you mind this information being shared with other

parents/teachers/Physicians/Etc.? Yes___ No___

Kim

" Bradley's Mom "

http://www.iqonline.net/murphy/bradley/lapeer.htm

http://www.MichiganFEAT.org

http://www.ark-inc.org