SEED - Questionaire Packets

Status: Original and derived artifacts are available for this document.

Download: doc | pdf | html


Study to Explore Early Development 
Checklist of Questionnaire Packets


All of these packets ask for information that will help us learn more about autism and developmental disabilities.  You can use this list to check off each of the items as you complete them.

First Questionnaire Packet	Total Time: 55-80 Minutes
This packet can be completed by you at your home or we can ask you the questions over the phone or at a visit to our clinic office.

    • Paternal Medical History	10 Minutes
Asks questions about medical and psychiatric diagnoses that a physician may have given your child’s biological father.

    • Maternal Medical History	10 Minutes
Asks questions about medical and psychiatric diagnoses that a physician may have given your child’s biological mother.

    • Autoimmune Disease Survey	20 Minutes
Asks questions about your family’s history of autoimmune diseases.  These questions are about your child and his/her biological mother and father and siblings.

    • Paternal Occupational Questionnaire	5 Minutes
Asks questions about your child’s biological father’s job title, industry, job duties and work duration for all jobs he had just before and during the pregnancy.  For fathers who are students, asks questions on his schooling.

    • Survey of Gastrointestinal Function	10 Minutes
Asks questions about any digestive problems your child may have now or in the past.

Second Questionnaire Packet	Total Time: 80 Minutes
This packet can be completed by you at your home or we can ask you the questions over the phone or at a visit to our clinic office.

    • Child Behavior Checklist	15 Minutes
Asks questions about any behavior problems your child may have.  Also asks about his/her social skills.

    • Carey Temperament Scale	10 Minutes
Asks questions about your child’s temperament (how he/she thinks, feels, acts, and reacts to different people or situations).

    • Child Sleep Habits Questionnaire	10 Minutes
Asks questions about your child’s sleep patterns, behaviors, and any sleep-associated medical conditions.

    • Social Responsiveness Scale (Child Version)	15 Minutes
Asks questions about how your child behaves in social settings.

    • Social Responsive Scale (Adult Version)	30 Minutes
Asks questions about how your child’s biological parents behave in social settings.  Two forms will be provided: one for your child’s biological mother and one for your child’s biological father.


Third Questionnaire Packet	Total Time: 60 Minutes
This packet can be completed by you at your home.

    • 3 Day Diet Diary 	20 Minutes
Asks you to record all of the foods and drinks your child has during a 3-day time period.  This includes foods eaten at home, at school or daycare, during play dates, etc.  The diet diary should be done during the first three days of the stool diary.

    • 7 Day Stool Diary	40 Minutes
Asks you to record all the bowel movements your child has during a 7-day time period.  The diet diary should be done during the first three days of the stool diary.