First Name* must provide value
Last Name* must provide value
Nickname
Gender* must provide value
Female
Male
Birthday* must provide value
Today M-D-Y
Address
Address Line 2
City
State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Zip Code
First Name
Last Name
Gender Female
Male
Is Caregiver A this child's biologic parent? Yes No
Home Phone Include Area Code
Cell Phone Include Area Code
E-mail
Same Address as this child? Yes No
Address
Address Line 2
City
State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Zip Code
First Name
Last Name
Gender Female
Male
Is Caregiver B this child's biologic parent? Yes No
Same Home Phone as Caregiver A? Yes No
Home Phone Include Area Code
Cell Phone Include Area Code
E-mail
Same Address as this child? Yes No
Address
Address Line 2
City
Zip Code
State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Is there another caregiver for this child? Yes No
First Name
Last Name
Home Phone Include Area Code
Cell Phone
Relationship to This Child
Person completing this form: Caregiver A
Caregiver B
Other Caregiver
Date of Form Completed: Today M-D-Y
Please indicate the Site this child is being seen at: Duke Einstein Harvard MIT STAR Center Seaver Autism Clinic UCSF University of Mass University of Wisconsin
Please indicate your concerns for this child's: Motor Skills
Language/Communication Skills
Learning/Academic Difficulties
Social Interaction Skills
Attention/Hyperactivity/Impulsivity
Mood/Emotional Regulation
Sensory Processing
Behavior
Headache
Seizure
Feeding
Other
Specify other concerns:
Total Number of Pregnancies (including this child) 1 2 3 4 5 6 7 8 9 10 >10
Total Number of Miscarriages 0 1 2 3 4 5 6 7 8 9 10 >10
Birth Order of This Child 1 2 3 4 5 6 7 8 9 10
Age gap between this child and previous child (specify in months) (If first pregnancy, write N/A):
Did mother need help getting pregnant (e.g., ART or IVF)? Yes No Don't Know
Were any of the following used to assist conception? Fertility medication
In Vitro Fertilization (IVF)
Intra-Cytoplasmic Sperm Injection (ICSI) Intrauterine Insemination (IUI)
Donor Egg
Donor Sperm
Surrogate mother
Other
Specify other assistance used for conception:
Did this child's birth mother have any medical problems or concerns during the pregnancy? Yes No Don't Know
Did this child's birth mother experience heavy bleeding during the pregnancy (not spotting)? Yes No Don't Know
Specify Trimester(s) for heavy bleeding: 1st Trimester
2nd Trimester
3rd Trimester
Was there concern that the baby was not growing enough? Yes No Don't Know
Specify Trimester(s) when there was concern that the baby was not growing enough: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother experience pre-term labor (<37 weeks)? Yes No Don't Know
Specify Treatment: Bed Rest
Magnesium
Specify Trimester(s) when mother experienced pre-term labor: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother have a cold or the flu? Yes No Don't Know
Specify Trimester(s) when mother had cold or flu: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother have a urinary tract infection (UTI)? Yes No Don't Know
Specify Trimester(s) when mother had a UTI: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother have increased levels of protein in her urine? Yes No Don't Know
Specify Trimester(s) when mother was found to have increased levels of protein in her urine: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother experienced pre-eclampsia, toxemia or hypertension? Yes No Don't Know
Specify Trimester(s) when mother experienced pre-eclampsia, toxemia or hypertension: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother have gestational diabetes? Yes No Don't Know
Specify Trimester(s) when mother had gestational diabetes: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother have other illness or problems? Yes No Don't Know
Specify other illness or problems:
Specify Trimester(s) when mother had other illness or problems 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother use prescribed medications? Yes No Don't Know
Specify number of prescription medications used: 1 2 3 4 5 >5
Please list all prescribed medication used during the pregnancy:
Specify Trimester(s) when mother used prescribed medications: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother take prenatal vitamins or supplements? Yes No Don't Know
Specify vitamin or supplement: Folate
Omega 3-Fatty Acid
Vitamin D
Multi-Vitamin
Other
Specify other vitamins or supplements:
Specify Trimester(s) when mother took prenatal vitamins or supplements: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother use alternative medication, diets, herbs, etc.? Yes No Don't Know
Specify alternative medications, herbs, etc. used:
Specify Trimester(s) when mother used alternative medication, diets, herbs, etc.: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother use street or "recreational" drugs? Yes No Don't Know
Specify street or "recreational" drugs used:
Specify Trimester(s) when mother used street or "recreational" drugs: 1st Trimester
2nd Trimester
3rd Trimester
Did this child's birth mother use alcohol? Yes No Don't Know
Specify Trimester(s) when mother used alcohol: 1st Trimester
2nd Trimester
3rd Trimester
Number of Drinks per Week: 0-1 2-4 5-8 >8
Did this child's birth mother use tobacco? Yes No Don't Know
Specify Trimester(s) when mother used tobacco: 1st Trimester
2nd Trimester
3rd Trimester
Number of Cigarettes per Day: 0 1 2 3 4 >4
Did this child's birth mother have medical procedures (e.g. X-rays)? Yes No Don't Know
Specify Trimester(s) when mother had medical procedures: 1st Trimester
2nd Trimester
3rd Trimester
Specify medical procedures:
Biological Mother's Age at Delivery (in years)
Biological Father's Age at Delivery (in years)
Birth Length (inches):
Birth Weight (specify pounds):
Birth Weight (specify ounces):
Birth Head Circumference (centimeters):
Length of Pregnancy (weeks):
Delivery Method Vaginal
C-Section
Assisted Delivery
Specify: Planned Emergency
Specify: Forceps
Vacuum
N/A
Length of Stay in Hospital for Baby (specify in days):
Specify if the labor was induced with: Pitocin
Strip Membrane (break water)
Other
Specify Other:
Specify:
Did this baby have medical problems or concerns during nursery stay? Yes No Don't Know
Baby had difficulty with early feeding (breast and/or bottle) Yes No Don't Know
Specify difficulty: Latch
Suck
Swallow
How long did difficulty with feeding last (specify in months)?
Did baby breast feed or receive breast milk in a bottle? Yes No Don't Know
How long did this child receive breast milk (specify in months)?
Did this baby have jaundice or high bilirubin? Yes No Don't Know
Specify treatment: Sunlight only
Bilirubin lights
Blood transfusion
Other
Specify other treatment:
Was the baby in the Neonatal Intensive Care Unit (NICU)? Yes No Don't Know
Specify how long (in days)?
Did baby receive brain or body cooling? Yes No Don't Know
Did baby receive cardiac support? Yes No Don't Know
Specify treatment: Blood Pressure Medications
ECMO
Other
Specify other treatment:
Specify how long (in days):
Did baby need help breathing during hospital stay? Yes No Don't Know
Specify treatment: Nasal Cannula
CPAP
Intubation
Other
Specify other treatment:
Did baby need a nasal-gastric (NG) tube for feeding? Yes No Don't Know
Specify how long (days)?
Did baby have blood infection or sepsis treated with antibiotics? Yes No Don't Know
Specify infection and treatment:
Did baby have brain infection (e.g., meningitis, encephalitis)? Yes No Don't Know
Specify brain infection and treatment (if known):
Baby had seizures treated with anticonvulsants Yes No Don't Know
Specify anticonvulsants if known:
Did baby have stroke or intraventricular hemorrhage (IVH)? Yes No Don't Know
Did baby have retinopathy of prematurity (ROP) Yes No Don't Know
Was baby born addicted? Yes No Don't Know
Specify addiction:
Did the birth mom have medical problems or concerns after birth? Yes No Don't Know
Did birth mom have "the blues" or depression? Yes No Don't Know
Specify severity: Mild
Moderate
Severe
Did mom have plugged ducts or mastitis? Yes No Don't Know
Other Problems or Concerns? Yes No Don't Know'
Specify:
Has this child lost previously attained abilities (e.g., started talking and/or walking and then stopped)? Yes No Don't Know
Specify domain of loss of skill: Language
Motor
Social
When loss skills were noted, was this child, fasting, ill, or experiencing trauma? Yes No Don't Know
Please describe:
Sits without support Yes No Don't Know
Specify the age that this child was able to sit without support (in months):
Walks without support Yes No Don't Know
Specify the age that this child was able to walk without support (in months):
Walks independently up steps Yes No Don't Know
Specify the age that this child was able to walk up steps (in months):
Jumps in place Yes No Don't Know
Specify the age that this child was able to jump in place (in months):
Hops on 1 foot Yes No Don't Know
Specify the age that this child was able to hop on one foot (in months):
Reaches for objects Yes No Don't Know
Specify the age that this child was able to reach for objects (in months):
Pinch or Grasp objects (e.g., pick up small objects with thumb and one finger) Yes No Don't Know
Specify the age that this child was able to pinch or grasp objects (in months):
Passes object hand to hand Yes No Don't Know
Specify the age that this child was able to pass objects from hand to hand (in months):
Scribbles spontaneously Yes No Don't Know
Specify the age that this child was able to scribble spontaneously (in months):
Copy Capital Letters Yes No Don't Know
Specify the age that this child was able to copy capital letters (in months):
Does This Child show hand preference for eating or drawing?* must provide value
Yes No Don't Know
Specify the age that this child showed hand preference (in months):
Specify hand preference for eating or drawing:* must provide value
Right Hand
Left Hand
Right and Left Hand Equally
Turns to Voice Yes No Don't Know
Specify the age that this child was able to turn to voice (in months):
Responds to "No" Yes No Don't Know
Specify the age that this child was able to respond to "No" (in months):
Points to 1 body part Yes No Don't Know
Specify the age that this child was able to point to one body part (in months):
Recognizes colors Yes No Don't Know
Specify the age that this child was able to recognize colors (in months):
Follows 2 or 3 step commands Yes No Don't Know
Specify the age that this child was able to follow 2 or 3 step commands (in months):
Babbles (e.g., "mama," "dada," or "uh-oh") Yes No Don't Know
Specify the age that this child was able to babble (e.g., "mama," "dada," or "uh-oh") (in months):
Says single words Yes No Don't Know
Specify the age that this child was able to say first word (in months):
Combines two words Yes No Don't Know
Specify the age that this child was able to combine two words (in months):
Can have a conversation with two or three sentences Yes No Don't Know
Specify the age that this child was able to have a conversation with 2 or 3 sentences (in months):
Echolalia (i.e., unusual or frequent repetition of words and phrases) Yes No Don't Know
Specify the age that this child began to use echolalic speech (in months):
Eye contact Yes No Don't Know
Specify the age that this child was able to show eye contact (in months):
Smiles back in response to someone smiling at him/her Yes No Don't Know
Specify the age that this child was able to smile back in response to someone smiling at him/her (in months):
Points to something of interest (i.e., spontaneously points at a person or object in sight just to show you) Yes No Don't Know
Specify the age that this child was able to point to something of interest (in months):
Interactive play Yes No Don't Know
Specify the age that this child was able to play interactively (in months):
Imaginative or pretend play Yes No Don't Know
Specify the age that this child was able to play imaginatively (in months):
Joint Attention (i.e., this child tries to attract your attention to his/her activity) Yes No Don't Know
Specify the age that this child was able to show joint attention (in months):
Toilet Trained during the Day with no accidents Yes No Don't Know
Specify the age that this child was toilet trained during the Day with no accidents (in months):
Toilet Trained during the Night with no accidents Yes No Don't Know
Specify the age that this child was toilet trained during the Night with no accidents (in months):
Were there any medical reasons for bed-wetting or bed-soiling? Yes No Don't Know
Describe the medical reasons for bed-wetting or bed-soiling:
As a baby did this child generally seem bored or uninterested in conversations around him/her? Yes No Don't Know
Describe:
Was this child referred to early intervention or other developmental services (e.g., PT, OT, speech or early intervention)? Yes No Don't Know
Specify therapy or intervention(s): Physical Therapy
Occupational Therapy
Speech and Language Therapy
Feeding Therapy
Applied Behavioral Analysis (ABA)
DIR/Floortine
Vision Therapy
Psychological or other Mental Health Therapy
Other
Age at Start of Physical Therapy (specify in months):
Specify if Physical Therapy was: School-Based
Center-Based
Home-Based
Duration of Physical Therapy (specify in months):
Age at Start of Occupational Therapy (specify in months):
Specify if Occupational Therapy was: School-Based
Center-Based
Home-Based
Duration of Occupational Therapy (specify in months):
Age at Start of Speech and Language Therapy (specify in months):
Specify if Speech and Language Therapy was: School-Based
Center-Based
Home-Based
Duration of Speech and Language Therapy (specify in months):
Age at Start of Feeding Therapy (specify in months):
Duration of Feeding Therapy (specify in months):
Age at Start of ABA (specify in months):
Duration of ABA (specify in months):
Duration of DIR/Floortine (specify in months):
Age at Start of DIR/Floortine (specify in months):
Age at Start of Vision Therapy (specify in months):
Duration of Vision Therapy (specify in months):
Age at Start of Psychological Therapy (specify in months):
Duration of Psychological Therapy (specify in months):
Age at Start of other therapy or intervention (specify in months):
Duration of other therapy or intervention (specify in months):
Specify therapy or intervention:
Is this child currently attending school? Yes No
Name of Current School
School District
City
Current Grade Level
Have you or this child's school been concerned about academic performance? Yes No Don't Know
Are you currently concerned that this child has had a spell or seizure? Yes No
Please specify your concerns:
Are you currently concerned that this child has headaches? Yes No
Please specify your concerns:
Are you concerned that this child currently has challenges with motor abilities (e.g., motor planning or postural control problems)? Yes No
Please specify your concerns:
Are you concerned that this child currently has sensory over-responsive, sensory under-responsive, and/or sensory craving? Yes No
Please specify your concerns:
Are you currently concerned that this child has tics or tremors? Yes No
Please specify your concerns:
Are you currently concerned that this child has a sleep disorder? Yes No
Please specify your concerns:
Does this child nap regularly? Yes No Don't Know
What time does this child currently go to bed? (Please specify time out of 24-hours) Now H:M
What time does this child currently fall asleep? Now H:M
What time does this child currently wake up in the morning? (Please specify time out of 24-hours) Now H:M
Has this child ever had any Surgical Procedures? Yes No
How many surgical procedures has this child had? 1 2 3 4 5 6 7 8 9 10 >10
(a) Specify surgical procedure:
(a) Specify date of surgical procedure: Today M-D-Y
(b) Specify surgical procedure:
(b) Specify date of surgical procedure: Today M-D-Y
(c) Specify surgical procedure:
(c) Specify date of surgical procedure: Today M-D-Y
(d) Specify surgical procedure:
(d) Specify date of surgical procedure: Today M-D-Y
(e) Specify surgical procedure:
(e) Specify date of surgical procedure: Today M-D-Y
(f) Specify surgical procedure:
(f) Specify date of surgical procedure: Today M-D-Y
(g) Specify surgical procedure:
(g) Specify date of surgical procedure: Today M-D-Y
(h) Specify surgical procedure:
(h) Specify date of surgical procedure: Today M-D-Y
(i) Specify surgical procedure:
(i) Specify date of surgical procedure: Today M-D-Y
(j) Specify surgical procedure:
(j) Specify date of surgical procedure: Today M-D-Y
(k) Specify surgical procedure:
(k) Specify date of surgical procedure: Today M-D-Y
Other Surgical Procedure(s):
Is this child currently being prescribed medication? Yes No Don't Know
How many different medications is this child currently taking? 1 2 3 4 5 >5
(a) Name of Medication
(a) Reason Prescribed:
(a) Age when prescribed (specify in years):
(a) Highest Dosage:
(a) Is this medication helpful? Yes No Don't Know
(b) Name of Medication
(b) Reason Prescribed:
(b) Age when prescribed (specify in years):
(b) Highest Dosage:
(b) Is this medication helpful? Yes No Don't Know
(c) Name of Medication
(c) Reason Prescribed:
(c) Age when prescribed (specify in years):
(c) Highest Dosage:
(c) Is this medication helpful? Yes No Don't Know
(d) Name of Medication
(d) Reason Prescribed:
(d) Age when prescribed (specify in years):
(d) Highest Dosage:
(d) Is this medication helpful? Yes No Don't Know
(e) Name of Medication
(e) Reason Prescribed:
(e) Age when prescribed (specify in years):
(e) Highest Dosage:
(e) Is this medication helpful? Yes No Don't Know
(f) Name of Medication
(f) Reason Prescribed:
(f) Age when prescribed (specify in years):
(f) Highest Dosage:
(f) Is this medication helpful? Yes No Don't Know
Other Current Medication(s)
Has this child been prescribed medication in the past? Yes No Don't Know
How many different medications has this child taken in the past? 1 2 3 4 5 >5
(a) Name of Medication
(a) Reason Prescribed:
(a) Age when prescribed (specify in years):
(a) Duration of Use:
(a) Highest Dosage:
(a) Reason Discontinued:
(a) Was this medication helpful? Yes No Don't Know
(b) Name of Medication
(b) Reason Prescribed:
(b) Age when prescribed (specify in years):
(b) Duration of Use:
(b) Highest Dosage:
(b) Reason Discontinued:
(b) Was this medication helpful? Yes No Don't Know
(c) Name of Medication
(c) Reason Prescribed:
(c) Age when prescribed (specify in years):
(c) Duration of Use:
(c) Highest Dosage:
(c) Reason Discontinued:
(c) Was this medication helpful? Yes No Don't Know
(d) Name of Medication
(d) Reason Prescribed:
(d) Age when prescribed (specify in years):
(d) Duration of Use:
(d) Highest Dosage:
(d) Reason Discontinued:
(d) Was this medication helpful? Yes No Don't Know
(e) Name of Medication
(e) Reason Prescribed:
(e) Age when prescribed (specify in years):
(e) Duration of Use:
(e) Highest Dosage:
(e) Reason Discontinued:
(e) Was this medication helpful? Yes No Don't Know
(f) Name of Medication
(f) Reason Prescribed:
(f) Age when prescribed (specify in years):
(f) Duration of Use:
(f) Highest Dosage:
(f) Reason Discontinued:
f) Was this medication helpful? Yes No Don't Know
Other Past Medication(s):
Has this child ever been on a restricted or special diet (e.g., gluten-free, casein-free)? Yes No Don't Know
Specify special diet: Gluten-Free Diet
Casein-Free Diet
Ketogenic Diet
Other
Is this child Currently on a Gluten-Free Diet? Yes No Don't Know
Was/Is the Gluten-Free Diet helpful? Yes No Don't Know
Is this child Currently on a Casein-Free Diet? Yes No Don't Know
Was/Is the Casein-Free Diet helpful? Yes No Don't Know
Is this child Currently on a Ketogenic Diet? Yes No Don't Know
Was/Is the Ketogenic Diet helpful? Yes No Don't Know
Is this child Currently on another diet? Yes No Don't Know
Was/Is this diet helpful? Yes No Don't Know
Specify other diet:
Immunizations Up-To-Date Not Up-To-Date
Explain:
Neuroimaging Prenatal Ultrasound
Postnatal Head Ultrasound
Head CT
MRI (Brain and/or Spine)
PET Scan
Electroencephalography (EEG)
Magnetoencephalography (MEG)
Other Organ Imaging Cardiac ECHO
Abdominal (Liver) Ultrasound
Renal (Kidney) Ultrasound
Skeletal Survey X-ray ("Bone Age")
Other
Specify Other Organ Imaging:
Has this child previously been evaluated by a Geneticist? Yes No Don't Know
Specify:
Genetic Testing for Biological Parents: Yes No Don't Know
Specify:
Pre-natal genetic testing for this child: Triple Screen
Nuchal Translucency
Chorionic Villus Sampling (CVS)
Amniocentesis
Non-Invasive Pre-natal Testing (NIPT)
Post-natal metabolic or genetic testing for this child: Newborn Screen
High Resolution Chromosome (Karyotype)
Chromosome Micro Array
Fragile X
Testing of Single Genes
Whole Exome Sequencing
Other Blood Work
Urine Studies
Cerebral Spinal Fluid Analysis
Muscle Analysis
Specify genes or conditions tested for:
Date of Most Recent Hearing Exam: Today M-D-Y
Was the hearing test normal? Yes No Don't Know
What is the type of hearing loss? Sensorineural
Conductive
Mixed
Date of Most Recent Vision Exam: Today M-D-Y
Does this child wear: glasses contacts
Specify: Farsighted (hyperopia)
Nearsighted (myopia)
Astigmatism
Strabismus
Wandering eye (exotropia)
Cross-eyed (esotropia)
Nystagmus (jerking eyes)
Lazy Eye (amblyopia)
Number of FULL Brother(s): 0 1 2 3 4 5 6 7 8 9 10 >10
Number of HALF Brother(s) (maternal): 0 1 2 3 4 5 6 7 8 9 10 >10
Number of HALF Brother(s) (paternal): 0 1 2 3 4 5 6 7 8 9 10 >10
Number of FULL Sister(s): 0 1 2 3 4 5 6 7 8 9 10 >10
Number of HALF Sister(s) (maternal): 0 1 2 3 4 5 6 7 8 9 10 >10
Number of HALF Sister(s) (paternal): 0 1 2 3 4 5 6 7 8 9 10 >10
Do the biologic parents, siblings, and/or this child have any history of allergic, immunologic and/or rheumatologic concerns (e.g., asthma, eczema, or lupus)? Yes No Don't Know
Specify Medicine Allergy:
Allergy to Medicine. Specify the maternal/paternal relative's relationship to this child:
Allergy to Food. Specify the maternal/paternal relative's relationship to this child:
Specify Food Allergy:
Specify Environmental Allergy:
Allergy to Environment. Specify the maternal/paternal relative's relationship to this child:
Asthma. Specify the maternal/paternal relative's relationship to this child:
Eczema. Specify the maternal/paternal relative's relationship to this child:
Rheumatoid Arthritis. Specify the maternal/paternal relative's relationship to this child:
Specify Autoimmune Disorder:
Autoimmune Disorder. Specify the maternal/paternal relative's relationship to this child:
Specify Other Allergy, Immunology, and/or Rheumatology History:
Other Allergy, Immunology, and/or Rheumatology History. Specify the maternal/paternal relative's relationship to this child:
Do the biologic parents, siblings, and/or this child have any history of blood and/or circulatory concerns (e.g., clotting disorders)? Yes No Don't Know
Clotting Disorder. Specify the maternal/paternal relative's relationship to this child:
Thalassemia. Specify the maternal/paternal relative's relationship to this child:
Other Blood or Circulatory History. Specify the maternal/paternal relative's relationship to this child:
Specify Other Blood or Circulatory History:
Do the biologic parents, siblings, and/or this child have any history of cardiovascular concerns (e.g., Congenital Heart Disease)? Yes No
Specify Congenital Heart Disease:
Congenital Heart Disease. Specify the maternal/paternal relative's relationship to this child:
Other Cardiovascular History. Specify the maternal/paternal relative's relationship to this child:
Specify Other Cardiovascular History:
Do the biologic parents, siblings, and/or this child have any history of congenital, genetic and/or metabolic concerns (e.g., cleft lip, Down Syndrome, or Spina Bifida)? Yes No
Specify Structural Birth Defect:
Structural Birth Defect. Specify the maternal/paternal relative's relationship to this child:
Down Syndrome. Specify the maternal/paternal relative's relationship to this child:
Fragile X Syndrome. Specify the maternal/paternal relative's relationship to this child:
Neurofibromatosis. Specify the maternal/paternal relative's relationship to this child:
Rett's Syndrome. Specify the maternal/paternal relative's relationship to this child:
Spina Bifida or Neural Tube Defect. Specify the maternal/paternal relative's relationship to this child:
Specify Skin Finding:
Skin Finding. Specify the maternal/paternal relative's relationship to this child:
Tuberous Sclerosis. Specify the maternal/paternal relative's relationship to this child:
Specify Unusual Facial Features:
Unusual Facial Features. Specify the maternal/paternal relative's relationship to this child:
Other Congenital, Genetic, and/or Metabolic History. Specify the maternal/paternal relative's relationship to this child:
Specify Other Congenital, Genetic and/or Metabolic History:
Do the biologic parents, siblings, and/or this child have any history of ears, nose, and/or throat concerns? Yes No
Recurrent Ear Infection. Specify the maternal/paternal relative's relationship to this child:
Specify Other Ears, Nose, and/or Throat History:
Other Ears, Nose, and/or Throat History. Specify the maternal/paternal relative's relationship to this child:
Do the biologic parents, siblings, and/or this child have any history of endocrine concerns (e.g., hyper/hypothyroidism, diabetes, or short stature)? Yes No
Hyperthyroidism. Specify the maternal/paternal relative's relationship to this child:
Hypothyroidism. Specify the maternal/paternal relative's relationship to this child:
Specify Diabetes: Type I Diabetes Type II Diabetes
Hyperglycemia or Diabetes. Specify the maternal/paternal relative's relationship to this child:
Hypoglycemia. Specify the maternal/paternal relative's relationship to this child:
Macrosomia. Specify the maternal/paternal relative's relationship to this child:
Short Stature. Specify the maternal/paternal relative's relationship to this child:
Specify Other Endocrine History:
Other Endocrine History. Specify the maternal/paternal relative's relationship to this child:
Do the biologic parents, siblings, and/or this child have any history of gastroenterologic concerns (e.g., constipation, diarrhea, or irritable bowel syndrome)? Yes No
Colic. Specify the maternal/paternal relative's relationship to this child:
Constipation. Specify the maternal/paternal relative's relationship to this child:
Diarrhea. Specify the maternal/paternal relative's relationship to this child:
Failure to Thrive. Specify the maternal/paternal relative's relationship to this child:
GERD. Specify the maternal/paternal relative's relationship to this child:
IBS. Specify the maternal/paternal relative's relationship to this child:
Inflammatory Bowel Disease. Specify the maternal/paternal relative's relationship to this child:
Recurrent Vomiting. Specify the maternal/paternal relative's relationship to this child:
Other Gastrointestinal History. Specify the maternal/paternal relative's relationship to this child:
Specify Other Gastrointestinal History:
Do the biologic parents, siblings, and/or this child have any history of musculoskeletal concerns (e.g., scoliosis)? Yes No
Scoliosis. Specify the maternal/paternal relative's relationship to this child:
Specify Other Musculoskeletal History:
Other Musculoskeletal History. Specify the maternal/paternal relative's relationship to this child:
Do the biologic parents, siblings, and/or this child have any history of neurologic concerns (e.g., dyslexia, migraines, learning disabilities, or epilepsy)? Yes No
Brain Infection. Specify the maternal/paternal relative's relationship to this child:
Cerebral Palsy. Specify the maternal/paternal relative's relationship to this child:
Cognitive Impairment or Mental Retardation. Specify the maternal/paternal relative's relationship to this child:
Dyslexia. Specify the maternal/paternal relative's relationship to this child:
Dysphagia. Specify the maternal/paternal relative's relationship to this child:
Headache or Migraine. Specify the maternal/paternal relative's relationship to this child:
Specify Head Injury:
Head Injury resulting in loss of consciousness. Specify the maternal/paternal relative's relationship to this child:
Hydrocephalus. Specify the maternal/paternal relative's relationship to this child:
Hypertonia or Spasticity. Specify the maternal/paternal relative's relationship to this child:
Hypotonia. Specify the maternal/paternal relative's relationship to this child:
Specify Learning Disability:
Learning Disability. Specify the maternal/paternal relative's relationship to this child:
Macrocephaly. Specify the maternal/paternal relative's relationship to this child:
Microcephaly. Specify the maternal/paternal relative's relationship to this child:
Muscular Dystrophy. Specify the maternal/paternal relative's relationship to this child:
Specify Repetitive Movement or Stereotypy:
Repetitive Movement or Stereotypy. Specify the maternal/paternal relative's relationship to this child:
RLS. Specify the maternal/paternal relative's relationship to this child:
Speech or Language Delay. Specify the maternal/paternal relative's relationship to this child:
Seizure Disorder or Epilepsy. Specify the maternal/paternal relative's relationship to this child:
Stroke or Hemorrhage. Specify the maternal/paternal relative's relationship to this child:
Tics or Tourette's Syndrome. Specify the maternal/paternal relative's relationship to this child:
Alzheimer's Disease or Dementia. Specify the maternal/paternal relative's relationship to this child:
Parkinson's Disease. Specify the maternal/paternal relative's relationship to this child:
Other Neurology History. Specify the maternal/paternal relative's relationship to this child:
Specify Other Neurology History:
Specify Brain Infection:
Specify Cognitive Impairment or Mental Retardation:
Do the biologic parents, siblings, and/or this child have any history of oncologic concerns (e.g., brain cancer)? Yes No
Specify Brain Cancer:
Brain Cancer. Specify the maternal/paternal relative's relationship to this child:
Specify Other Oncology History:
Other Oncology History. Specify the maternal/paternal relative's relationship to this child:
Do the biologic parents, siblings, and/or this child have any history of psychiatric concerns (e.g., anxiety, ADHD, Autism Spectrum Disorder, Bipolar Disorder, or depression)? Yes No
Aggression to Self or Others. Specify the maternal/paternal relative's relationship to this child:
Specify Alcohol or Drug Addiction:
Alcohol or Drug Addiction. Specify the maternal/paternal relative's relationship to this child:
Specify Auditory or Visual Hallucinations:
Auditory or Visual Hallucinations. Specify the maternal/paternal relative's relationship to this child:
Anorexia or Bulimia. Specify the maternal/paternal relative's relationship to this child:
Specify Anxiety Disorder:
Anxiety Disorder. Specify the maternal/paternal relative's relationship to this child:
Attention Deficit/Hyperactivity Disorder. Specify the maternal/paternal relative's relationship to this child:
Autism Spectrum Disorder, Asperger's Syndrome or PDD/NOS. Specify the maternal/paternal relative's relationship to this child:
Specify Autism Spectrum Disorder, Asperger's Syndrome or PDD/NOS:
Bipolar Disorder. Specify the maternal/paternal relative's relationship to this child:
Conduct Disorder. Specify the maternal/paternal relative's relationship to this child:
Specify Conduct Disorder:
Depression. Specify the maternal/paternal relative's relationship to this child:
Obsessive Compulsive Behavior. Specify the maternal/paternal relative's relationship to this child:
Specify Obsessive Compulsive Behavior:
Suicide attempt. Specify the maternal/paternal relative's relationship to this child:
Other Psychiatric History. Specify the maternal/paternal relative's relationship to this child:
Specify Other Psychiatric History:
Do the biologic parents, siblings, and/or this child have any history of sensory concerns (e.g., over-responsive to sound or touch)? Yes No
Does This Child Currently have Atypical Gaze? Yes No
Atypical Gaze. Specify the maternal/paternal relative's relationship to this child:
Does This Child Currently have Cravings for Sensory Input? Yes No
Specify craving for sensory input if other than movement or auditory:
Craves Sensory Input. Specify the maternal/paternal relative's relationship to this child:
Is This Child Currently Under-Responsive to Sound and/or Touch? Yes No
Specify if under-responsive to something other than sound or touch:
Under-Responsive to Sound and/or Touch stimulus. Specify the maternal/paternal relative's relationship to this child:
Is This Child Currently Over-Responsive to Sound or Hyperacusis? Yes No
Over-Responsive to Sound or Hyperacusis. Specify the maternal/paternal relative's relationship to this child:
Specify type of sound over-responsiveness:
Is This Child Currently Over-Responsive to Touch? Yes No
Specify type of touch over-responsiveness:
Over-Responsive to Touch. Specify the maternal/paternal relative's relationship to this child:
Other Sensory History. Specify the maternal/paternal relative's relationship to this child:
Specify Other Sensory History:
Are the biologic mother and father related by blood (e.g., cousins)? Yes No Don't Know
Are there other family members who share this child's challenges or traits? (please select, N/A, if this child is typical, a control, or adopted) Yes No Don't Know N/A
Describe:
What countries are this child's biologic mother's relatives originally from?
What countries are this child's biologic father's relatives originally from?
What is the Primary Language spoken in the home?
Does this child speak any other languages? Yes No
Specify other language(s) this child speaks:
Specify Primary Caregiver A's occupation:
Specify Primary Caregiver B's occupation:
Number of other persons living in this child's household (not including Caregiver A and/or Caregiver B or this child)? 0 1 2 3 4 5 >5
Person 1. Specify Name:
Person 1. Gender: Female
Male
Person 1. Specify Birthday: Today M-D-Y
Person 1. Relationship to this child:
Person 2. Specify Name:
Person 2. Gender: Female
Male
Person 2. Specify Birthday: Today M-D-Y
Person 2. Relationship to this child:
Person 3. Specify Name:
Person 3. Gender: Female
Male
Person 3. Specify Birthday: Today M-D-Y
Person 3. Relationship to this child:
Person 4. Specify Name:
Person 4. Gender: Female
Male
Person 4. Relationship to this child:
Person 4. Specify Birthday: Today M-D-Y
Person 5. Specify Name:
Person 5. Gender: Female
Male
Person 5. Relationship to this child:
Person 5. Specify Birthday: Today M-D-Y
Other Persons:
At what age was this child adopted (specify in months)?
From what country was this child adopted?
Please tell us how long it took you to complete this form? 0-15minutes
15-30minutes
30-45minutes
45-60minutes
>60minutes
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