Self-Administered Forms (Mother)

Study ID #: ______________

Date of Completion _________________

Study to Explore Early Development

FATHER’S MEDICAL AND OCCUPATIONAL HISTORY

Respondent’s relationship to the study child:

□ Biological Father □ Biological Mother □ Other: Specify _________________

Father’s Medical History

Instructions: Please tell us if the child’s biological father has ever been diagnosed with any of these conditions. If you check “Yes,” tell us the age at diagnosis and type, if requested (where the space is clear and not shaded in the “specify type” column). Keep in mind these conditions must have been diagnosed by a doctor. See the glossary of terms if you don’t know the meaning of a condition.
	Has a doctor or other health care provider ever told you/him that you/he have any of the following conditions?
Condition	No/ Don’t Know	Yes	Age of Diagnosis (years)	Specify type
Addison’s disease	□	□
Allergies	□	□
Ankylosing spondylitis	□	□
Anxiety disorder	□	□
Aplastic anemia	□	□
Asperger’s syndrome	□	□
Asthma	□	□
Attention-deficit/hyperactivity disorder	□	□
Autism	□	□
Autoimmune hepatitis	□	□
Bipolar disorder	□	□
Birth defect	□	□
Bleeding/clotting disorders	□	□
Byler disease or intrahepatic cholestasis	□	□
Condition	No/ Don’t Know	Yes	Age of Diagnosis (years)	Specify type
Cardiovascular condition	□	□
Celiac disease	□	□
Cerebral palsy	□	□
Childhood disintegrative disorder (CDD)	□	□
Crohn’s disease	□	□
Cystic fibrosis	□	□
Depression	□	□
Dermatitis herpetiformis	□	□
Diabetes: Uses insulin	□	□
Diabetes: Does not use insulin	□	□
Down syndrome	□	□
Eating disorder (i.e., bulimia, anorexia)	□	□
Eczema/psoriasis	□	□
Endocrine disorder (hormonal disorder)	□	□
Fragile X syndrome	□	□
Gastrointestinal disorders	□	□
Giant Cell arteritis	□	□
Graves disease	□	□
Guillain-Barre syndrome	□	□
Hashimoto thyroiditis	□	□
Hearing impairment	□	□
Hemolytic anemia	□	□
High blood pressure	□	□
Hyperthyroidism	□	□
Hypothyroidism	□	□
Irritable bowel syndrome	□	□
Learning disability	□	□
Liver disease	□	□
Lupus, or systemic lupus erythematosus (SLE)	□	□
Mental retardation - Intellectual Disability	□	□
Migraine headaches	□	□
Condition	No/ Don’t Know	Yes	Age of Diagnosis (years)	Specify type
Motor problem/movement or coordination problem	□	□
Multiple sclerosis	□	□
Myasthenia gravis	□	□
Narcolepsy	□	□
Neurofibromatosis	□	□
Neuromuscular disorder	□	□
Obesity	□	□
Obsessive compulsive disorder	□	□
Optic neuritis	□	□
Pemphigus	□	□
Personality disorder	□	□
Pervasive developmental disorder	□	□
Reading difficulty	□	□
Reiter’s syndrome	□	□
Respiratory condition	□	□
Rheumatoid arthritis	□	□
Schizophrenia	□	□
Scleroderma (progressive systemic sclerosis, CREST)	□	□
Seizure disorder/epilepsy	□	□
Self-injuring behavior	□	□
Sickle cell anemia/ thalassemia/other hereditary anemias	□	□
Sjogren’s syndrome	□	□
Sleep disorder	□	□
Speech problem	□	□
Stevens-Johnson syndrome	□	□
Suicide attempt	□	□
Sydenham’s chorea	□	□
Thrombocytopenia, (immune, idiopathic)	□	□
Tourette’s syndrome	□	□
Tuberous sclerosis	□	□
Ulcerative colitis	□	□
Vision impairment	□	□
Other: Specify condition below
1.	□	□
2.	□	□
3.	□	□
4.	□	□
5.	□	□

Father’s Occupational History

We are interested in the father’s main job or educational activity during the year before the child’s birth. Think of a main job as one that took at least 10 hours per week and lasted for at least one month. If more than one job was worked, please answer about the job worked the most during this period.

1. What was the father’s main employment during the year before the child was born (the period just before the mother became pregnant until the child’s birth)?

□ EMPLOYED

□ STUDENT, specify the field of study_________________, Degree sought________

□ UNPAID WORK, VOLUNTEER

□ UNEMPLOYED

□ OTHER, please specify: ______

Please continue if the father was employed. If not, you are finished with this section.

2. What was the main job title or occupation during this time?

________________________________________________________________________

3. What type of business was this, or what did the company make or do?

________________________________________________________________________

4. Please check the time periods this job was worked around the mother’s pregnancy and child’s birth.

□ just before the mother became pregnant

□ during first 3 months of the mother’s pregnancy

□ during the middle 3 months of the mother’s pregnancy

□ during the last 3 months of the mother’s pregnancy

5. Describe the main duties or activities for this job.

Version 9-2015 Page 4 of 4