Dear Concerned Parent or Parent-to-be, START HERE. Take five minutes to complete our complimentary Autism Risk Review. Determine your risk level and learn some simple changes you can make in your environment and lifestyle right away. In designing this questionnaire, I’ve incorporated known and suspected risk factors identified from my years of experience working with families, and in the medical literature. It is designed to be sensitive, and to help guide parents toward changes in their lifestyle which will increase the chances of a healthy pregnancy. PLEASE NOTE: This assessment is NOT designed to diagnose, predict autism risk or substitute for medical care. Instead it is intended to educate and help you address important changes to help you grow a healthy child. - John Green MD Please enter your Email ID before starting the quiz: Email Name 1 For prospective mothers- Check all that apply. Do you or your biological child (if applicable) have any of the following: Autism Spectrum Disorder (ADD or PD-NOS) Asperger Syndrome ADHD Anaphylaxis Autoimmune disorder (e.g. Lupus, Rheumatoid Arthritis, Celiac disease) Other behavioral, learning or sensory disorders (diagnosed or undiagnosed) 2 For prospective mothers- Check all that apply. Do you have a close relative (sibling, parent, aunt or uncle) who has: Autism Spectrum Disorder (ASD or PDD-NOS) Asperger Syndrome ADHD or ADD Anaphylaxis (life threatening allergy) Autoimmune disorder (e.g Lupus, Rheumatoid arthritis, Celiac disease) Other behavioral, learning or sensory disorders (diagnosed or undiagnosed) 3 For prospective mothers- Do you have a history of infertility or miscarriage? Yes No 4 For prospective mothers- Do you have a history of in vitro fertilization? Yes No 5 For prospective mothers- Are you older than 40? Yes No 6 For prospective mothers- Have you had a C section? Yes No 7 For prospective mothers- Do you take one of these prescription medications: Prozac (fluoxetine) Zoloft (sertraline) Other SSRI Depakote or Depakene (valproic acid)? Yes Yes, but I am planning to stop before becoming pregnant No 8 For prospective mothers- Check all that apply. Do you have a family history (parents, sibling, aunt or uncle) of any of the following diseases? Neurodegenerative disorders (e.g. ALS, Parkinson's Alzheimers, MS) Schizophrenia Severe depression (including suicide) Premature cardiovascular disease (onset before age 50) Type 2 diabetes Cancer 9 For prospective mothers- Do you have mercury ("silver") fillings in your mouth? None 1-2 fillings 3-4 fillings 5 or more fillings 10 For prospective mothers- Have you received the flu vaccine (which contains aluminum or thimerosal as preservatives) in the last 5 years? No, I requested a flu shot without preservatives. Yes, 1 shot in the last 5 years Yes, 2 shots in the last 5 years Yes, 3 shots in the last 5 years Yes, 4 shots in the last 5 years Yes, 5 shots in the last 5 years 11 For prospective mothers- Do you live in a home built before 1975, or have you been exposed to lead through water or soil contamination? Yes No 12 For prospective mothers- Are you regularly or heavily exposed to pesticides? Examples are living near commercially sprayed fields or Christmas tree farms, golf courses, treated lawns or homes fumigated for pest control. Yes No 13 For prospective mothers- Has your home been remodeled or re-carpeted with synthetic material in the last 5 years? Yes No 14 For prospective mothers- Do you live near an oil refinery, coal fired power plant, large trash burner or Superfund site? Yes No 15 For prospective mothers- Do you work in or have regular exposure to a toxic environment? Examples are welding, electronics manufacture, working with volatile compounds such as varnishes, indoor shooting range, solvents, lacquers, volatile glues, etc. Yes No 16 For prospective mothers- Do you smoke cigarettes? Yes No 17 For prospective mothers- Do you live within two blocks or a freeway or very busy street? Yes No 18 For prospective mothers- Do you live within 1/2 mile of a cell phone tower? Yes No 19 For prospective mothers- Do you have a smart meter on your house? Smart meters are being used by utility companies to remotely measure gas or electricity consumption and emit regular pulsed radiation. Yes No 20 For prospective mothers- Do you have wifi in your home? Yes No 21 For prospective mothers- Do you have a cordless landline phone in your home? If you don't know what this is, the answer is no. Yes No 22 For prospective mothers- Do you use a cell phone? Yes, but I use a headset and don't carry it on my body Yes No 23 For prospective fathers- Check all that apply. Do you or your biological child (if applicable) have any of the following: Please note: If you are the biological father of a child mentioned in question #1 and your child has any of the following issues, please check the last option: "Yes I have a child with one of these conditions..." Autism Spectrum Disorder (ADD or PD-NOS) Asperger Syndrome ADHD Anaphylaxis Autoimmune disorder (e.g. Lupus, Rheumatoid Arthritis, Celiac disease) Other behavioral, learning or sensory disorders (diagnosed or undiagnosed) Yes, I have a child with one of these conditions, but they were accounted for in question #1. 24 For prospective fathers- Check all that apply. Do you have a close relative (sibling, parent, aunt or uncle) who has: Autism Spectrum Disorder (ASD or PDD-NOS) Asperger Syndrome ADHD or ADD Anaphylaxis (life threatening allergy) Autoimmune disorder (e.g Lupus, Rheumatoid arthritis, Celiac disease) Other behavioral, learning or sensory disorder (diagnosed or undiagnosed) 25 For prospective fathers- Are you older than 45? Yes No 26 Do you have a history of male infertility? Yes No 27 For prospective fathers- Check all that apply. Do you have a family history (parents, sibling, aunt or uncle) of any of the following diseases? Neurodegenerative disorders (e.g. ALS, Parkinson's Alzheimers, MS) Schizophrenia Severe depression (including suicide) Premature cardiovascular disease (onset before age 50) Type 2 diabetes Cancer 28 For prospective fathers- Do you have mercury ("silver") fillings in your mouth? None 1-2 fillings 3-4 fillings 5 or more fillings 29 For prospective fathers- Have you received the flu vaccine (which contains aluminum or thimerosal as preservatives) in the last 5 years? No, I requested a flu shot without preservatives. Yes, 1 shot in the last 5 years Yes, 2 shots in the last 5 years Yes, 3 shots in the last 5 years Yes, 4 shots in the last 5 years Yes, 5 shots in the last 5 years 30 For prospective fathers- Do you work in or have regular exposure to a toxic environment? Examples are welding, electronics manufacture, working with volatile compounds such as varnishes, indoor shooting range, solvents, lacquers, volatile glues, etc. Yes No 31 For prospective fathers- Do you smoke cigarettes? Yes No 32 For prospective fathers- Do you live within 1/2 mile of a cell phone tower? Yes No 33 For prospective fathers- Do you have a smart meter on your house? Smart meters are being used by utility companies to remotely measure gas or electricity consumption and emit regular pulsed radiation. Yes No 34 For prospective fathers- Do you have wifi in your home? Yes No 35 For prospective fathers- Do you have a cordless landline phone in your home? If you don't know what this is, the answer is no. Yes No 36 For prospective fathers- Do you use a cell phone? Yes, but I use a headset and don't carry it on my body Yes No Time's up
