Self Administered Forms

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

Attachment 8.b. Paternal and Occupational Medical History SEED 3

Self Administered Forms

OMB: 0920-1171

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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


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

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