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This survey is designed for caretakers (parents or guardians) to fill out about their children. Any information you provide will be kept secure and used solely to help researchers who study autism. Please answer the following questions to the best of your ability. If you have any questions about or problems with the survey, please e-mail us at info@thinkcomputer.org. Thanks for your support!

By taking this survey you acknowledge that you may be disclosing confidential medical information to Think Computer Foundation, a non-medical establishment, and authorize Think Computer Foundation to use this information for research purposes, which may involve sharing this information with other organizations.

First Name
Last Name
Address 1
Address 2
Postal Code
Home Phone
Gender Female    Male   
Birth Date   
Are you the person listed above or a relative or guardian?
  Yes, I am the person listed above.    No, I am a relative or guardian.   
Do you believe that anyone else in your family is autistic?
  Yes    No   
Did someone direct you to this site?
  Yes    No   
If so, please provide the following information:
Referral Name
Referral E-Mail
1. If any, which of the following medical diagnoses has your child been given by medical professionals?
  Asperger's Syndrome
  Attention Deficit Disorder (ADD)
  Attention Deficit Hyperactivity Disorder (ADHD)
  Autistic Spectrum Disorder (ASD)
  Bi-Polar Disorder
  Fragile X Syndrome
  Learning Disabilities (LD)
  Pervasive Developmental Disorder (PDD)
  Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS)
  None of the Above
2. Does your child have any other serious medical problems, related or unrelated to autism? If so, please describe them.
3. How old was your son or daughter when you noticed signs of autism?
  Less Than 6 Months
Between 6 Months - 1 Year
Between 1 Year and 2 Years
Between 2 Years and 3 Years
Between 3 Years and 4 Years
Between 4 Years and 7 Years
Between 7 Years and 10 Years
Greater Than 10 Years
4. Please describe the first sign of something being "wrong" that you remember noticing in your child's appearance or behavior. Be as descriptive as possible.
5. Please describe any additional signs you noticed thereafter. Be as descriptive as possible.
6. Did you ever notice that your child had a larger or oddly-shaped head relative to other children of similar age at any point in time? If so, please describe what and when you noticed.
7. Does your child exhibit repetitive behavior? If so, please describe it.
8. Does your child exhibit obsessive tendencies? If so, please describe them.
9. Does your child have violent tantrums more often (in your opinion) than other children?
  Yes    No   
10. If your child has a tantrum, is there usually a particular cause that you can identify?
11. Does your child have difficulty smiling for photographs in a manner than you have actively noticed?
  Yes    No   
12. Does your child have any trouble recognizing faces? If so, please describe how.
13. Check the box next to any group your child interacts well with.
  Younger children
  Children of the same age
  Older children
14. Check the box next to any group that your child does not interact well with.
  Younger children
  Children of the same age
  Older children
15. Does your child seek out social relationships with other non-disabled children?
  Yes    No   
16. If your child's IQ has been tested, please choose the range that it falls into.
  Below 70
Greater Than 150
17. Does your child have any visual or hearing problems (e.g. glasses, hearing loss, etc.)? If so, please describe them.
18. Does your child have any problems speaking? If so, please describe them.
19. About how many mental health professionals do you estimate your child has seen?
20. Has your child been treated with any prescription medications? Check all that apply.
  Abilify (aripiprazole)
  Anafranil (cloripramine)
  Buspar (buspitrone HCl, USP)
  Dilantin (phenytoin)
  Luvox (fluxovamine)
  Periactin (cyproheptadine)
  Prozac (fluoxetine HCl)
  Risperdal (risperidone)
  Ritalin (methylphenidate)
  Trexan (naltrexone)
  Seroquel (quetiapine fumarate)
  Xanax (alprazolam)
  Zoloft (sertraline HCl)
21. Has any treatment in particular been successful in treating your child's symptoms?
22. Has your child ever undergone any sort of brain imaging study for the purpose of better understanding his or her mental health condition? Check all that apply.
  Head CT
  Magnetic Resonance Imaging (MRI)
  Functional Magnetic Resonance Imaging (fMRI)
23. Have you found your local public school to be capable of handling your child's needs?
  Yes    No   
24. Have you found your local or state government to be capable of assisting your child?
  Yes    No   

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