Self Administered Forms

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

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