Thank you for your interest in participating in the following medical questionnaire. It is our hope that you will download the questionnaire and return it as soon as possible.

The information from this questionnaire will help us considerably in determining possible causes of Asperger Syndrome that can be looked at with careful research later. This information will be used to supplement the questionnaire you may have received from Yale-LDAA Asperger Study.

Please return this questionnaire either directly to LDAA at 4156 Library Road, Pittsburg, Pennsylvania 15234 attention: Dr. Ken Bonnet or, by e-mail to Dr. Ken Bonnet

Please use each question to trigger your memory. Please give all details you can, even if you don't remember the specific name of something, or only remember parts of the details.

We hope that you may wish to identify yourself so that we may send you feedback from this questionnaire. If you prefer, however, you may omit the following identity questions.

1. PERSON COMPLETING QUESTIONNAIRE:

   Name:
   
   Address:
   
   Relationship to individual with Asperger syndrome:
   
   

2. INDIVIDUAL WITH ASPERGER SYNDROME:

   Name:
   
   Sex:
   
   Age:
   
   

PLEASE COMPLETE THE FOLLOWING WITH AS MUCH DETAIL AS YOU WISH

1. What medications were taken during pregnancy? Please list all medications.
   
   
   
2. What medical conditions were present during pregnancy? Please include previous or current thyroid disorders, or any other medical condition preceding or arising during the pregnancy.
   
   
   
3. Did the mother smoke during pregnancy?
   
   
   
4. Was the mother taking any supplements (e.g. vitamins, calcium,zinc, etc.) during pregnancy?
   
   
   
5. What conditions existed during pregnancy? (For example, was there any premature labor, any premature spotting, any conditions requiring bed rest, and any flu, cold, shortness of breath and yawning, or other episodes like "chronic fatigue", or "malaise" during pregnancy)? Please list all that can be remembered and give approximate month of the pregnancy when it occurred.
   
   
   
6. Did any other family member have a viral disease during pregnancy?
   
   
   
7. Were any medication used during the delivery (to induce delivery, to delay delivery, and to treat medical conditions of the mother or the infant during delivery)?
   
   
   
8. Was there any complication, for the mother of infant at delivery? Include Apgar score if available, was there any "blue baby" or jaundice or temperature regulation disorder?
   
   
   
9. Is there any history of psychiatric conditions in the family of the mother or father, or both? Include obsessive-compulsive, Tourette syndrome, tics, language disorders, depression, etc. Please specify which side of family, etc., for each.
   
   
   
10. Was there any early childhood infection before age 5 years? Please describe all that can be remembered. Include severity, treatment if any, and what effect this left on the child (even if the illness was not diagnosed completely).
    
    
    
11. Is there a history of any neurological disorder, auditory processing problems, deafness, or "unusual" relative on the mother's or father's side, or among the child's siblings or cousins? Please describe all that you can.
    
    
    
12. How long was the delivery? What was the birth weight?
    
    
    
13. Have there been any spontaneous abortions, still births, or children that failed to thrive from the same mother prior or after this child?
    
    
    
14. Have there been any spontaneous abortions, stillbirths or children that failed to thrive from any other family members on either the mother's or father's side?
    
    
    
15. Were there any signs of delayed development in the first year that caught the mother's attention?
    
    
    
    
16. What was the quality of the baby's cry? How was it different?
    
    
    
17. How do you describe the baby's suck after birth?
    
    
    
18. Was there anything unusual about the odor of the baby's urine?
    
    
    
19. Did your child ever run high fevers of sudden onset without obvious cause? Was there a history of headaches?
    
    
    
20. Did this child startle to sudden noises the same way as other children in the first year?
    
    
    
21. Did this child seem to "ignore" you talking or voice at any period of development?
    
    
    
22. What about the response to warnings said emphatically to the child at any period of development (compared to other children)?
    
    
    
23. Did this child seem to have unusual motor coordination or fine motor coordination during early development? Describe.
    
    
    
24. Was there over or under reaction to unpleasant sensory stimulation? If so, how would you characterize it?
    
    
    
25. Is there any person in the family cluster that has depression, psychosis, or seizures?
    
    
    
26. Please describe any details of the Asperger syndrome individual that was noteworthy in pregnancy, birth, infancy, and development.
    
    
    
27. Has the individual with Asperger syndrome had any brain imaging (MRI, CT, brain scans, PET, SPECT) studies at any time, for any reason?
    
    
    
28. What about EEG or evoked potentials?
    
    
    
29. Please describe any details about needs for services for the AS individual or the family.
    
    
    
30. Please describe any details about needs for professional/ educational upgrading about Asperger and Nonverbal Learning Disabilities.
    
    
    
31. Please describe any needs for information, services, professional help you wish to convey.
    
    
    
    
    

Thank you for completing this questionnaire. Please feel free to add any additional comments, needs, statements or wishes. We have worked with Asperger syndrome for 11 years and see the need to focus real and informed concerns into formal statements of needs for advocacy for individuals and families that can be communicated to LDAA.

Click Here to send an e-mail to Dr. Bonnet