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Kindly fill in the questionnaire and email it back at

Your correct data can help us solve the mystery of autism and decrease its prevalence.

ASSESSING RISKFACTORS OF AUTISM

I. Demographic Data

Name of city living: ______Age: ______

Gender: MaleFemale

Location (city) of Birth: ______Birth Order: ______

Immunization:CompleteIncompleteUp to Age

Family Marriage: Yes No

Family history of any type of Psychotic Disease: Yes No

Email address; ______

II. Maternal Characteristics

  1. Maternal age:______
  2. Paternal age:______
  3. Mothers health status (can tick more than one)
  4. Smoking
  5. Gestational Diabetes
  6. Hypertension
  7. Severe Anemia
  8. Depression
  9. If any other; please specify______
  10. Any use of medication during pregnancy: YesNO
  11. Please specify if yes:______
  12. Any use of contraceptives: YesNo
  13. Any previous miscarriage: YesNo

III. Delivery and Pregnancy Characteristics:

  1. Duration of Pregnancy:
  1. Pre term (Before expected date of delivery)
  2. Term (On expected date of deliver)
  3. Post term(After expected date of delivery)
  1. Complication during pregnancy (can tick more than one):
  1. Bleeding in second trimester (During 4,5 and 6 month)
  2. Bleeding in third trimester (During 7,8,9 months)
  3. Edema
  4. Increase frequency of vomiting
  5. Fits other than epilepsy
  6. Uncontrolled Blood pressure
  7. Any other please specify:______
  1. Place of Birth:
  1. Hospital
  2. Home
  3. Dispensary
  4. Any other please specify: ______
  1. Delivery was conducted by:
  1. Doctor
  2. Nurse
  3. Dai
  4. Relative
  5. Any other please specify
  1. Mode of Delivery:
  1. Normal Vaginal Delivery,
  2. LSCS
  3. Instrumental
  1. Any anesthesia taken during pregnancy: Yes No
  2. If Y then specify:
  1. Spinal
  2. Epidural
  3. G/A
  1. Complication during delivery:
  1. Breech
  2. Prolonged Labor
  3. Prematurely
  1. Did you take antenatal care: YesNo

IV. Neonatal Risk Factors:

  1. Tick if your child experienced any one of the following;
  1. Low Birth Weight ( less than 2.5 kg)
  2. Jaundice
  3. Seizure
  4. Asphyxia
  5. Any congenital malformation.
  6. Any other; please specify______

V. Diagnosis and Sign Symptoms:

  1. Age at time of diagnosis: ______
  2. Who picked it up first?
  1. Parents
  2. Teachers
  3. Doctors
  4. Other specify ______
  1. Who confirmed the diagnosis? ______
  2. Tick the following sign and symptoms that were/are present in your child.

i. Social Impairment

  1. Lack of eye-to-eye contact
  2. Poor facial expression
  3. Poor gesture
  4. Lack of interest in daily activities environment

ii. Impairment in communication

  1. Delay or lack of spoken language
  2. Unable to initiate or sustain speech
  3. Repetitive use of language

iii. Repetitive movements (hands or finger flapping)

iv. Persistent preoccupation with objects.

v. Any other sign or symptom besides above (please specify): ______

22. Any suggestion:

______

Thank you for your time