Parent Survey

Three-Minute Survey for Parents of Children with Autism and/or Other Neurodevelopmental Disorders

This brief parent survey will help the Escher Fund for Autism develop new grants to support research into some of the possible causes of autism and other neurodevelopmental disorders. Surveys like this one have already shaped more than a half-dozen studies at major research institutions and several papers and commentaries in major scientific journals. This survey is not itself a research project—no data will be used in any study. Rather, it merely serves to help raise questions that may be investigated in future research projects.

All information will be kept completely confidential unless at a later time you provide explicit permission to share some portion of your information. That said, if you are uncomfortable supplying answers that's fine, you could respond with general answers, say "prefer not to answer," or request to deliver your information in a telephone conversation (just email us).

Otherwise, please fill out all boxes to the best of your knowledge. If the answer is no or you don't know, simply indicate that. When completed, please hit "submit." Your information is for screening purposes only. We will contact you with any follow-up questions.

Thank you for your participation!

* Indicates required field

Your name *

Email address *

Please specify the ages and diagnoses of your biological children (including no diagnosis) *

For any of your children, did either of their biological grandmothers smoke during pregnancy with either of the biological parents? If yes, explain. *

For any of your children, did either of their biological grandmothers undergo any fertility, anti-miscarriage or anti-preterm birth treatments during pregnancy with either of the biological parents? If yes, explain. *

For any of your children, please indicate if either of their biological grandmothers took medications for any of the following conditions during pregnancy with a biological parent: Epilepsy or seizures, depression or mental illness, asthma, diabetes, morning sickness or other conditions? If yes, explain. *

For any of your children, did either of their biological grandmothers undergo surgical procedures during pregnancy with either of the biological parents (for example, an emergency appendectomy, problems with the uterus/placenta, etc)? If yes, explain. *

Was either biological parent born prematurely and/or by Cesarean section? If yes, please explain. *

Has either biological parent taken chemotherapy? Or medication for seizures or epilepsy? (That is, before the birth of your last child) *

Please share the surgeries (using general anesthesia) experienced by either biological parent prior to the conception of the children. This includes surgeries in infancy, childhood, adolescence and adulthood. Please include the ages at which these surgeries occurred. *

Please feel free to share any other comments. *

You are all done, please hit the Submit box below. Thank your for participating!

Submit