Complete the Questionnaire

Complete the Questionnaire

John Green MD > Complete the Questionnaire

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:
2) For prospective mothers-

Check all that apply.
Do you have a close relative (sibling, parent, aunt or uncle) who has:
3) For prospective mothers-

Do you have a history of infertility or miscarriage?
4) For prospective mothers-

Do you have a history of in vitro fertilization?
5) For prospective mothers-

Are you older than 40?
6) For prospective mothers-

Have you had a C section?
7) For prospective mothers-

Do you take one of these prescription medications:
Prozac (fluoxetine)
Zoloft (sertraline)
Other SSRI
Depakote or Depakene (valproic acid)?
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?
9) For prospective mothers-

Do you have mercury ("silver") fillings in your mouth?
10) For prospective mothers-

Have you received the flu vaccine (which contains aluminum or thimerosal as preservatives) 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?
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.
13) For prospective mothers-

Has your home been remodeled or re-carpeted with synthetic material in the last 5 years?
14) For prospective mothers-

Do you live near an oil refinery, coal fired power plant, large trash burner or Superfund site?
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.
16) For prospective mothers-

Do you smoke cigarettes?
17) For prospective mothers-

Do you live within two blocks or a freeway or very busy street?
18) For prospective mothers-

Do you live within 1/2 mile of a cell phone tower?
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.
20) For prospective mothers-

Do you have wifi in your home?
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.
22) For prospective mothers-

Do you use a cell phone?
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..."
24) For prospective fathers-

Check all that apply.
Do you have a close relative (sibling, parent, aunt or uncle) who has:
25) For prospective fathers-

Are you older than 45?
26) Do you have a history of male infertility?
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?
28) For prospective fathers-

Do you have mercury ("silver") fillings in your mouth?
29) For prospective fathers-

Have you received the flu vaccine (which contains aluminum or thimerosal as preservatives) 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.
31) For prospective fathers-

Do you smoke cigarettes?
32) For prospective fathers-

Do you live within 1/2 mile of a cell phone tower?
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.
34) For prospective fathers-

Do you have wifi in your home?
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.
36) For prospective fathers-

Do you use a cell phone?