ASPERGER SYNDROME
MEDICAL QUESTIONNAIRE
LEARNING DISABILITIES ASSOCIATION OF AMERICA
4156 Library Road
Pittsburgh, Pennsylvania 15234
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 l5234 or,
by e-mail to Dr. Ken Bonnet (bbmw@pipeline.com)
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.
PERSON COMPLETING QUESTIONNAIRE:
Name:
Address:
Relationship to individual with Asperger syndrome:
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.
________________________________________________________________________
Please return this by e-mail to: bbmw@pipeline.com
or by postal mail to:
Jean Peterson
attn: Andrea for Dr.Bonnet
LDAA
4156 Library Road
Pittsburgh, PA 15234
Thank you for completing this. 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.
Home to O.A.S.I.S.