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Child's Name: Date of Birth: Birth Weight: Length: Head Circumference: Child's order of birth (first child, second child, third child, etc.) Doctor/Obstetrician: Address: Telephone: How many months pregnant were you when you first saw a doctor? How many times did you see the doctor during your pregnancy? Name of hospital where child was born: Address: Telephone: Child was in the hospital from to date date Name of child's primary doctor in the hospital: Specialty: Address: Telephone: Child's APGAR Scores: 1 minute 5 minutes Name of hospital child was transferred to: Address: Telephone: Reason for transfer: Child was in this hospital from to date date Name of child's doctor: Specialty: Address: Telephone: Drugs/medication taken by mother before/during pregnancy: 1. 2. 3. 4. Mother's illnesses during pregnancy: 1. 2. 3. 4. Was baby full term (9 months)? Yes No If No, How many weeks Early or Late was the baby born? Early Late Length of Labor: Type of delivery: Normal Breech Caesarean Child's condition at birth: Child's problems following birth: Did mother have problems with other pregnancies? Birth defects: NO YES If YES please choose type head deformities body deformities limb deformities heart deformities kidney deformities stomach/intestine deformities Sepsis (bacterial blood infection) NO YES Jaundice, hyperbilirubinemia, yellow skin NO YES If YES what treatment was given (circle all that apply) No treatment, phototherapy (special lights), exchange transfusion (blood transfusion) Seizures NO YES Meningitis NO YES High fever (>38.5 or 101.5) NO YES Other NO YES ______________________________ Did the birth mother breast feed the baby? ______________________________ How old was the child in months when s/he received the last/final breast milk feeding? ______________________________ Did the baby have any difficulty with feeding (breast or bottle)? ______________________________ Did the baby have a poor suck? ______________________________ Did the baby require special feeds ( e.g. thickened liquid or special nipples)? ______________________________ When did this happen? ______________________________ Did the baby have trouble gaining weight? ______________________________ How was the baby’s early temperament? (Circle one.) - Easy - Fussy or colicky - Quiet or passive - Can’t say ______________________________ How was the baby’s early sleep pattern? (Circle one.) - Regular/Predictable - Irregular/Unpredictable - Can’t say ______________________________ Questions regarding medical problems for the child in the study. ______________________________ Birth Defects ______________________________ Is there any known abnormality in this area? ______________________________ If YES, check all that apply: Cleft lip Cleft palate Ears deformed Nose deformity Arms, legs, hands, feet, trunk deformities Spine defect (spina bifida) Head/Face/Mouth Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Early closing of the sutures (craniosynostosis) Dental or Tooth Deformity (shape, enamel, number, location) Regurgitation through nose Other (list: __________________________________________) Eyes Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Abnormal structure of the eye Strabismus (lazy eye) Color blindness Poor vision Blindness Other (list: __________________________________________) Ears Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Ears set too low or too high Tinnitus (ringing in the ear) Recurrent Infections Number per year when happening most frequently_____________ Ear tubes placed Hearing trouble How was this diagnosed? ______________ At what age was the child when this was diagnosed? ________ Other (list: __________________________________________) Nose/throat Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Nosebleeds Trouble perceiving smells Too sensitive to smells Tonsillitis Snoring Tonsillectomy Adenoidectomy Other (list: _________________________________________) Neck/Back Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Deformity (scoliosis, lordosis, kyphosis, torticollis) Other (list: ___________________________________________) Orthopedic Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Fractures Muscle/bone/joint pain Edema (swelling caused by excess fluid) Stiffness Joint swelling Heat or redness of joints Other (list: _______________________________________) Skin Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Eczema Psoriasis Frequent rashes Unexplained sores Infections Sensitive Birth marks Other (list: ________________________________________) Pulmonary Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Shortness of breath Asthma Recurrent pneumonias Chonic bronchitis Blood in sputum Other (list: ________________________________________) Cardiovascular Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Congenital heart disease Heart murmur Blue discoloration to skin and lips (cyanosis) Heart rate too slow or too fast or not rhythmic (arrhythmia) Other (list: _______________________________________) Gastrointestinal Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Poor appetite Swallowing difficulty Overeating Severe abdominal pain Abdominal bloating Chronic Diarrhea Chronic Constipation Blood in stool Pus in stool Unexpected weight loss or weight gain Gastroesophageal reflux (GERD) Indigestion Pica (eating non-food materials) Excessively picky eater Other (list: _________________________________) Genito-Urinary Is there any known abnormality in this area of development? NO YES DON’T KNOW If YES, check all that apply: Deformity (ambiguous genitalia, hypospadias, etc.) Undescended testicles Testicle too large, too small, too hard, with lump Pain with urination Blood in urine Discharge Urinating too frequently, too seldom Urinary tract infection Other (list: _________________________________) Endocrine/Metabolic Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Problems with thyroid gland Swelling of neck Diabetes Hypoglycemia (documented low blood sugar) Significantly overweight or underweight History of failure to thrive as an infant Too tall for age Too short for age Overweight for age Underweight for age Gaining weight too fast, too slow Growing taller too slowly, too fast Developing sexually too fast, too slow Difficulty regulating body temperature (gets too hot or too cold) Unusual body odor or smell Unusual smell of the urine Child often shows a regression or loss of skills during illnesses Tires more easily than other children Unusual response to anesthesia Other (list: _________________________________) Allergic/Immunologic Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Allergies TYPE: Circle all that apply: FOOD ENVIRONMENTAL (dust, pets, etc) SEASONAL (hayfever) OTHER: Immunodeficiency (immune system doesn’t work right) TYPE: __________________________ Autoimmune disorder (Immune system overactive) TYPE: _____________________________ Swelling of lymph nodes (glands) Frequent infections Hematologic/Cancer Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Anemia (low red blood count) Tires more easily than other children Paleness Cancer TYPE: _______________________________________ Infectious Diseases Has the child had any of the following illness? NO YES DON’T KNOW If YES, check all that apply: Influenza Roseola Fifth’s disease ) Rubella (German Measles) Rubeola (measles) Mumps Chicken Pox Herpes Type 1 (cold sores) Herpes Type 2 (genital) Lyme disease Epstein Barr Virus (mononucleosis) Cytomegalovirus (CMV) Viral Hepatitis Neurological Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Headache Muscle rigidity Tremor Tic movements Dystonia (a slow movement or extended spasm in a group of muscles) Akathisia (restlessness of arms and legs) History of meningitis or encephalitis Dizziness/faintness Unusual walking pattern Balance trouble Coordination trouble Weakness Loss of consciousness Severe sleep disturbance Seizures with fever only Seizures without fever (epilepsy) Speech articulation difficulties Speech or oral-motor apraxia Whole body apraxia (motor planning difficulty) Psychiatric Is there any known abnormality in this area? NO YES DON’T KNOW If YES, check all that apply: Diagnosed with ADHD Trouble with attention or concentration Excessively distractable Hyperactive Diagnosed with depression Diagnosed with bipolar/ manic depression Diagnosed with anxiety disorder Diagnosed with OCD Diagnosed with Schizophrenia Panic attacks Hallucinations Self injurious behavior Been admitted to a psychiatric hospital Genetic Syndromes Is there any known abnormality in this area of development? NO YES DON’T KNOW If YES, check all that apply: Fragile X Tuberous Sclerosis Neurofibromatosis Rett Syndrome Angelman Syndrome Prader Willi Syndrome Other chromosomal abnormality, disorder, or syndrome (specify): ____________________ Diagnostic Tests and Procedures the Child has had Has the child ever had his/her hearing tested? NO YES DON’T KNOW If YES circle all that apply and tell us HOW OLD THE CHILD WAS WHEN TESTED Age at test Date Location Behavioral audiometry ABR or BEAR Tympanogram Otoacoustic emissions Has the child ever had a brain scan? NO YES DON’T KNOW If YES circle all that apply and tell us HOW OLD THE CHILD WAS WHEN SCANNED Age at test Date Location CAT or CT scan MRI scan MRS scan SPECT scan PET scan Other _______________ Has the child ever had an EEG or MEG (test of the brain waves)? NO YES DON’T KNOW If YES circle all that apply and tell us HOW OLD THE CHILD WAS WHEN HE/SHE HAD THE EEG. Age at test Date Location EEG MEG OTHER (repeat EEGs, ERP’s etc) ______________________________ History of SURGERIES and HOSPITALIZATIONS Has the child ever had surgery? ______________________________ Has the child had any other hospitalizations besides these surgeries? ______________________________ If YES, please fill in the table below WHY HOSPITALIZED HOW MANY DAYS DID HE/SHE STAY DATE 14 V1 2.8.07 History of Medications, Supplements, Special Diets Is the child currently on any prescription medication? ?? No ?? Yes ?? Not sure 1) 2) 3) 4) If yes please list: ______________________________ In the past has the child been on prescription medication to help with his/her symptoms of _________? ______________________________ Please indicate all other medical treatments used to treat the child’s symptoms of autism? ?? Now ?? In the past ?? Never ?? Not sure Chelating medications ?? Now ?? In the past ?? Never ?? Not sure Hyperbaric oxygen chamber ?? Now ?? In the past ?? Never ?? Not sure Supplemental vitamins ?? Now ?? In the past ?? Never ?? Not sure Herbal supplements such as Gingko or Echinacea ?? Now ?? In the past ?? Never ?? Not sure Fatty acid supplements? ?? Now ?? In the past ?? Never ?? Not sure Amino acid supplements? ?? Now ?? In the past ?? Never ?? Not sure Mineral supplements like iron or zinc? ?? Now ?? In the past ?? Never ?? Not sure Is the child’s diet limited in any way to help behaviors? Gluten free Casein free Feingold No processed sugars No sugars or salicylates Other: _____________________ Has the diet been helpful? ?? Now ?? In the past ?? Never ?? Not sure ?? Now ?? In the past ?? Never ?? Not sure ?? Now ?? In the past ?? Never ?? Not sure ?? Now ?? In the past ?? Never ?? Not sure ?? Now ?? In the past ?? Never ?? Not sure ?? Now ?? In the past ?? Never ?? Not sure ?? Now ?? In the past ?? Never ?? Not sure NO YES CAN’T SAY PART IV Questions regarding family history for the child participating in the study. Many people don’t know their family medical history very well and sometimes it helps to ask extended family members if they know anyone in the family who has had various illnesses or conditions. Below is a list of things we are interested in and we would like to know if they have been seen in the child’s blood relatives (siblings, mother and/or father, grandparents, aunts, uncles or cousins). TYPE OF DISORDER EXAMPLES WHO HAD IT? Autism Asperger’s PDD-NOS Autism Spectrum Disorders: Childhood Disintegrative Disorder Rett Syndrome Fragile X Tuberous Sclerosis Neurofibramatosis Prader Willi or Angelman Syndrome Down Syndrome Other genetic syndrome (eg Sotos syndrome, Joubert syndrome, Williams syndrome) Phenylketonuria (PKU) Genetic Disorders or Syndromes: Chromosomal abnormalities (deletions, duplications) Mental retardation Speech delay requiring therapy Developmental Problems Learning Disabilities |