Thank you for showing interest in this research study!
How did you find out about our study?
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The Autism Network (ATN) at CHLA Boone Fetter Clinic at CHLA The University Center for Excellence in Developmental Disabilities (UCEDD) at CHLA The Division of Dentistry & Orthodontics at CHLA UCLA Pediatric Therapy Network (PTN) Therapy West Center for Developing Kids (CDK) Dr. Susan Spitzer The Help Group Another therapist or doctor Your child's school A friend or family member PEERS Facebook or Instagram Other
*(Please select any of the above methods or institutions that provided you information on our study)
Therapist's or Doctor's Name
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School Name
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Other
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How many of your children are interested in participating?
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1
2
3
more than 3
Is at least one parent able to do an extensive interview and questionnaires about early development, fluently, in English?
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Yes
No
Is your child between 8 years and 17 years 11 months old?
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Yes
No
Which best describes your child?
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Right Handed
Left Handed
Ambidextrous
Child's first name
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(What is the full legal name of your child interested in our study?)
Child's last name
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Please provide your child's date of birth:
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Today M-D-Y
Current age
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View equation Child sex
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Male
Female
(What is their sex?)
Autism Spectrum
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Yes
No
(Do they have a diagnosis on the autism spectrum?)
What is your child's ethnicity?
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Hispanic or Latino
Non-Hispanic or Latino
Does not wish to disclose
(Hispanic or Latino = A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin regardless of race.)
What is your child's race?
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(Hispanic or Latino = A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin regardless of race.)
Please provide your child's parent's first name
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Please provide your child's parent's last name
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Please indicate their relation to your child
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Mother
Father
Other
Other Relationship
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Please provide your child's other parent's first name
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Please provide your child's other parent's last name
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Please indicate their relation to your child
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Mother
Father
Other
Other Relationship
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Is English the primary language spoken in your home?
Yes
No
What is the primary language in your home?
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Other primary language:
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What percent is English spoken at home?
(Place a mark on the scale above)
What percent is your primary language spoken at home?
(Place a mark on the scale above)
Are there any languages besides your primary language and English spoken at home?
Yes
No
What is the other language spoken in your home?
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Other language:
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What percent is your secondary language spoken at home?
(Place a mark on the scale above)
Call-Cell
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Call-Home
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Call-Office
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Email
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Cell phone number
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Contact email address
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Is your child fully verbal?
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Yes
No
Can your child be understood by others if they talk?
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Yes
No
Is your child in general education, performing at grade level in both reading and math?
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Yes
No
At what age/grade level have teachers estimated him/her to be functioning?
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What type of educational supports or resources does your child receive if any?
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Has your child ever received cognitive (IQ) testing?
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Yes
No
Do you know the results?
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Yes
No
What type of test was done?
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When was it done?
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(If unknown type "unknown")
Do you have any general comments regarding your child's cognitive ability to participate in the study?
Does your child currently experience or have a history of seizures or epilepsy?
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Yes
No
Has your child had any seizure experience in the last year?
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Yes
No
Has your child taken any medications for seizures within the last year?
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Yes
No
Please provide details
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Has your child experienced any significant brain injury, brain disease, or brain malformation?
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Yes
No
If your child has experienced a concussion, did they experience a loss of consciousness at the time of the incident?
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Yes
No
Please provide details
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Have you or anyone else had any concerns about your child or his/her siblings' development or possible signs of Autism Spectrum Disorders?
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Yes
No
What are your concerns?
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Has your child received any diagnosis or treatment for neurologic, psychiatric, or developmental (learning disability, dyslexia) disorders? OR Has your child been referred to any specialists for any suspected developmental or psychiatric disorder (e.g. intellectual disability schizophrenia, or bipolar disorder)?
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Yes
No
Please provide details
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Has the doctor ever ordered genetic tests for your child?
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Yes
No
Doesyour child have any known genetic condition other than Autism Spectrum Disorder?
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Yes
No
Please list which tests and indicate if they were positive or not.
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Is your child currently taking medications or supplements?
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Yes
No
Please list the names of the medications that your child is currently taking and their purpose.
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Does your child have any severe hearing loss or hearing impairments?
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Yes
No
Does your child have any vision problems?
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Yes
No
Please specify the corrective method
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Was your child born around his/her due date?
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Yes
No
How many days or weeks early or late was your child?
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How much did your child weigh at birth?
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Was your child born after 36 weeks?
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Yes
No
Did your child stay in the NICU?
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Yes
No
How many days was your child's NICU stay?
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For what reason?
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Did your child need oxygen support to breathe?
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Yes
No
How long was oxygen support provided?
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What type was given?
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Tent
bag
CPAP mask
Unknown
Did your child require mechanical ventilation (i.e. CPAP) due to an inability to breathe independently for a prolonged period of time?
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Yes
No
Did your child suffer from a brain bleed at birth?
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Yes
No
Have doctors ever given any other medical explanation for your child's difficulties?
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Yes
No
Provide details
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Does your child have any siblings? How many?
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0
1
2
3
(select the number of siblings)
Are they full biological siblings?
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All
Some
None
Is this sibling a full biological sibling?
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Yes
No
First sibling's age
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First sibling's interest in participating
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Interested
Not interested
Unsure
Second sibling's age
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Is this sibling a full biological sibling?
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Yes
No
Second sibling's interest in participating
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Interested
Not interested
Unsure
Third sibling's age
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Is this sibling a full biological sibling?
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Yes
No
Third sibling's interest in participating
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Interested
Not interested
Unsure
Has anyone in your family (including 2nd degree relatives - aunts, uncles, nephews, nieces, grandparents, cousins) been diagnosed with ASD?
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Yes
No
Which family members?
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Would you be interested in being contacted by other researchers at USC for future studies?
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Yes
No
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