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 No4. For prospective mothers- Do you have a history of in vitro fertilization? Yes No5. For prospective mothers- Are you older than 40? Yes No6. For prospective mothers- Have you had a C section? Yes No7. 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 No8. 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 Cancer9. For prospective mothers- Do you have mercury ("silver") fillings in your mouth? None 1-2 fillings 3-4 fillings 5 or more fillings10. 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 years11. 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 No12. 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 No13. For prospective mothers- Has your home been remodeled or re-carpeted with synthetic material in the last 5 years? Yes No14. For prospective mothers- Do you live near an oil refinery, coal fired power plant, large trash burner or Superfund site? Yes No15. 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 No16. For prospective mothers- Do you smoke cigarettes?YesNo17. For prospective mothers- Do you live within two blocks or a freeway or very busy street?YesNo18. For prospective mothers- Do you live within 1/2 mile of a cell phone tower?YesNo19. 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.YesNo20. For prospective mothers- Do you have wifi in your home?YesNo21. 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.YesNo22. For prospective mothers- Do you use a cell phone?Yes, but I use a headset and don't carry it on my bodyYesNo23. 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?YesNo26. Do you have a history of male infertility?YesNo27. 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 Cancer28. For prospective fathers- Do you have mercury ("silver") fillings in your mouth?None1-2 fillings3-4 fillings5 or more fillings29. 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 yearsYes, 2 shots in the last 5 yearsYes, 3 shots in the last 5 yearsYes, 4 shots in the last 5 yearsYes, 5 shots in the last 5 years30. 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.YesNo31. For prospective fathers- Do you smoke cigarettes?YesNo32. For prospective fathers- Do you live within 1/2 mile of a cell phone tower?YesNo33. 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.YesNo34. For prospective fathers- Do you have wifi in your home?YesNo35. 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.YesNo36. For prospective fathers- Do you use a cell phone?Yes, but I use a headset and don't carry it on my bodyYesNoTime is Up! Time's up
