Self Administered Forms

The Study to Explore Early Development (SEED) - Phase 3

Attachment 8.a. Maternal Medical History _ SEED 3

Self Administered Forms

OMB: 0920-1171

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Study ID #: ______________

Date of Completion___________

Study to Explore Early Development


MOTHER’S MEDICAL HISTORY


Respondent’s relationship to the study child:

Biological Mother □ Biological Father □ Other: Specify _________________


Instructions: Please tell us if your child’s biological mother 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. Also, having symptoms or being treated for a particular condition during pregnancy would be defined as having the condition during pregnancy.


Has a doctor or other health care provider ever told you/her that you/she have any of the following conditions?



Condition

No/ Don’t Know

Yes

Age of Diagnosis (years)

Specify type

Did you/she have the condition during pregnancy with the study child?

Addison’s disease



Yes □ No

Allergies



Yes □ No

Ankylosing spondylitis



Yes □ No

Anxiety disorder



Yes □ No

Aplastic anemia



Yes □ No

Asperger’s syndrome



Yes □ No

Asthma



Yes □ No

Attention-deficit/hyperactivity disorder



Yes □ No

Autism



Yes □ No

Autoimmune hepatitis



Yes □ No

Bipolar disorder



Yes □ No

Birth defect



Yes □ No

Bleeding/clotting disorders



Yes □ No

Condition

No/ Don’t Know

Yes

Age of Diagnosis (years)

Specify type

Did you/she have the condition during pregnancy with the study child?

Byler Disease or intrahepatic cholestasis



Yes □ No

Cancer



Yes □ No

Cardiovascular condition



Yes □ No

Celiac disease



Yes □ No

Cerebral palsy



Yes □ No

Childhood disintegrative disorder (CDD)



Yes □ No

Cholestasis (Obstetric or Intrahepatic during pregnancy)



Yes □ No

Crohn’s disease



Yes □ No

Cystic fibrosis



Yes □ No

Depression



Yes □ No

Dermatitis herpetiformis



Yes □ No

Diabetes: Uses insulin



Yes □ No

Diabetes: Does not use insulin



Yes □ No

Diabetes: Gestational (during pregnancy only)



Yes □ No

Down syndrome



Yes □ No

Eating disorder (i.e., bulimia, anorexia)



Yes □ No

Eczema/psoriasis



Yes □ No

Endocrine disorder (hormonal disorder)



Yes □ No

Fragile X syndrome




Yes □ No

Gastrointestinal disorders



Yes □ No

Giant Cell arteritis



Yes □ No

Graves disease



Yes □ No

Guillain-Barre syndrome



Yes □ No

Hashimoto thyroiditis



Yes □ No

Hearing impairment



Yes □ No

Hemolytic anemia



Yes □ No

Condition

No/ Don’t Know

Yes

Age of Diagnosis (years)

Specify type

Did you/she have the condition during pregnancy with the study child?

High blood pressure



Yes □ No

Hyperthyroidism



Yes □ No

Hypothyroidism



Yes □ No

Irritable bowel syndrome



Yes □ No

Learning disability



Yes □ No

Liver disease



Yes □ No

Lupus, or systemic lupus erythematosus (SLE)



Yes □ No

Mental retardation – Intellectual Disability



Yes □ No

Migraine headaches



Yes □ No

Mixed connective tissue disease



Yes □ No

Motor problem/movement or coordination problem



Yes □ No

Multiple sclerosis



Yes □ No

Myasthenia gravis



Yes □ No

Narcolepsy



Yes □ No

Neurofibromatosis



Yes □ No

Neuromuscular disorder



Yes □ No

Obesity



Yes □ No

Obsessive compulsive disorder



Yes □ No

Optic neuritis



Yes □ No

Pemphigus



Yes □ No

Personality disorder



Yes □ No

Pervasive developmental disorder



Yes □ No

Reading difficulty



Yes □ No

Reiter’s syndrome



Yes □ No

Respiratory condition



Yes □ No

Rheumatoid arthritis



Yes □ No

Schizophrenia



Yes □ No

Condition

No/ Don’t Know

Yes

Age of Diagnosis (years)

Specify type

Did you/she have the condition during pregnancy with the study child?

Scleroderma (progressive systemic sclerosis, CREST)



Yes □ No

Seizure disorder/epilepsy



Yes □ No

Self-injuring behavior



Yes □ No

Sickle cell anemia/ thalassemia/other hereditary anemias



Yes □ No

Sjogren’s syndrome



Yes □ No

Sleep disorder



Yes □ No

Speech problem



Yes □ No

Stevens-Johnson syndrome



Yes □ No

Suicide attempt



Yes □ No

Sydenham’s chorea



Yes □ No

Thrombocytopenia, (immune, idiopathic)



Yes □ No

Tourette’s syndrome



Yes □ No

Tuberous sclerosis



Yes □ No

Ulcerative colitis



Yes □ No

Vision impairment



Yes □ No

Other: Specify condition below



Yes □ No

1.



Yes □ No

2.



Yes □ No

3.



Yes □ No

4.



Yes □ No

5.



Yes □ No










Version 9-2015 Page 4 of 4

File Typeapplication/msword
File TitleStudy Start Maternal MedHX 2007
AuthorUNC
Last Modified ByJohnson-James, Treana (CDC/ONDIEH/NCBDDD) (CTR)
File Modified2016-09-12
File Created2015-09-18

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