Questionaire Packets

Appendix E.13 Maternal Medical History

Form Approved

OMB NO. __________

Exp. Date __________

Study ID #: ______________

S tudy to Explore Early Development

MATERNAL MEDICAL HISTORY FORM

Respondent (Please indicate your relationship to study child):

□ Biological Mother □ Biological Father □ Step Mother

□ Step Father □Maternal Grandparent □Paternal Grandparent

□ Other: Specify ___________________

Instructions: Indicate whether or not the biological mother of the study child has/had the condition listed by placing a  in the appropriate ‘Yes’ column. If you marked ‘Yes’ for any of the conditions please fill out the remaining information for that condition. Please keep in mind that these conditions must have been diagnosed by a doctor. Also, having symptoms or being treated for a particular condition during pregnancy would be defined as having the condition during pregnancy. If you are unclear about the definition of some of the conditions, please see the glossary of terms attached. If the biological mother of the study child does/did not have the condition listed; or if you are unclear about whether the biological mother has/had the condition listed, please check the box in the ‘No/Don’t know’ column.
Condition	Yes	No/Don’t know	Specify	Age of Onset	Did you/she have the condition during pregnancy with CHILD?
Allergies	□	□			□ Yes □ No
Asperger’s Syndrome	□	□			□ Yes □ No
Attention deficit hyperactivity disorder	□	□			□ Yes □ No
Anxiety disorder	□	□			□ Yes □ No
Autism
Bipolar disorder	□	□			□ Yes □ No
Birth defect	□	□			□ Yes □ No
Bleeding/clotting disorders	□	□			□ Yes □ No
Cancer	□	□			□ Yes □ No
Cardiovascular condition	□	□			□ Yes □ No
Cerebral Palsy	□	□			□ Yes □ No
Childhood Disintegrative Disorder (CDD)	□	□			□ Yes □ No
Cystic fibrosis	□	□			□ Yes □ No
Depression	□	□			□ Yes □ No
Down Syndrome	□	□			□ Yes □ No
Eating disorder (i.e., bulimia, anorexia)	□	□			□ Yes □ No
Endocrine disorder (hormonal disorder	□	□			□ Yes □ No
Fragile X Syndrome	□	□			□ Yes □ No
Condition	Yes	No	Specify	Age of Onset	Did you have the condition during your pregnancy with CHILD? (Yes or No)
Gastrointestinal disorders	□	□			□ Yes □ No
Hearing impairment	□	□			□ Yes □ No
High blood pressure	□	□			□ Yes □ No
Learning disability	□	□			□ Yes □ No
Mental retardation	□	□			□ Yes □ No
Motor problem/movement or coordination problem	□	□			□ Yes □ No
Neurofibromatosis	□	□			□ Yes □ No
Neuromuscular disorder	□	□			□ Yes □ No
Obesity	□	□			□ Yes □ No
Obsessive compulsive disorder	□	□			□ Yes □ No
Personality disorder	□	□			□ Yes □ No
Pervasive developmental disorder	□	□			□ Yes □ No
Reading difficulty	□	□			□ Yes □ No
Respiratory condition	□	□			□ Yes □ No
Rett’s Syndrome	□	□			□ Yes □ No
Schizophrenia	□	□			□ Yes □ No
Self-injuring behavior	□	□			□ Yes □ No
Seizure disorder/epilepsy	□	□			□ Yes □ No
Sickle cell anemia/ thalassemia/other hereditary anemias	□	□			□ Yes □ No
Sleep disorder	□	□			□ Yes □ No
Speech Problem	□	□			□ Yes □ No
Suicide attempt	□	□			□ Yes □ No
Tuberous sclerosis	□	□			□ Yes □ No
Vision impairment	□	□			□ Yes □ No
Other. Specify condition.	□	□			□ Yes □ No
1.	□	□			□ Yes □ No
2.	□	□			□ Yes □ No
3.	□	□			□ Yes □ No
4.	□	□			□ Yes □ No
5.	□	□			□ Yes □ No

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

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