SEED - Questionaire Packets

Form Approved

OMB NO. 0920-0741

Exp. Date 6/30/2010

Study ID #: ______________

Date of Completion___________

Study to Explore Early Development

MATERNAL MEDICAL HISTORY

Respondent’s relationship to the study child:

□ Biological Mother □ Biological Father □ Step Mother

□ Step Father □ Maternal Grandparent □ Paternal Grandparent

□ Other: Specify ___________________

Instructions: Check whether or not the biological mother of the study child has or had the conditions that follow. If you check “Yes” for any of the conditions, please fill out the other information for that condition. Please keep in mind that these conditions must have been diagnosed by a doctor. Also, having symptoms or being treated for a particular condition during pregnancy would be defined as having the condition during pregnancy. In the Specify column, please indicate the particular type of the more general condition. If you are unsure about the definition of some of the conditions, please see the glossary of terms provided. If you still don’t know the meaning of the condition after reviewing the Glossary, please check the box in the “Don’t Know” column.
Condition	No/ Don’t Know	Yes	Specify	Age of Onset	Did you/she have the condition during pregnancy with the study child?
Allergies	□	□			□ Yes □ No
Asperger’s syndrome	□	□			□ Yes □ No
Attention-deficit/hyperactivity disorder	□	□			□ Yes □ No
Anxiety disorder	□	□			□ Yes □ No
Autism	□	□			□ Yes □ No
Bipolar disorder	□	□			□ Yes □ No
Birth defect	□	□			□ Yes □ No
Bleeding/clotting disorders	□	□			□ Yes □ No
Cancer	□	□			□ Yes □ No
Cardiovascular condition	□	□			□ Yes □ No
Cerebral palsy	□	□			□ Yes □ No
Childhood disintegrative disorder (CDD)	□	□			□ Yes □ No
Cystic fibrosis	□	□			□ Yes □ No
Depression	□	□			□ Yes □ No
Down syndrome	□	□			□ Yes □ No

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0741)

Condition	No/ Don’t Know	Yes	Specify	Age of Onset	Did you/she have the condition during pregnancy with the study child?
Eating disorder (i.e., bulimia, anorexia)	□	□			□ Yes □ No
Endocrine disorder (hormonal disorder)	□	□			□ Yes □ No
Fragile X syndrome	□	□			□ Yes □ No
Gastrointestinal disorders	□	□			□ Yes □ No
Hearing impairment	□	□			□ Yes □ No
High blood pressure	□	□			□ Yes □ No
Learning disability	□	□			□ Yes □ No
Mental retardation	□	□			□ Yes □ No
Motor problem/movement or coordination problem	□	□			□ Yes □ No
Neurofibromatosis	□	□			□ Yes □ No
Neuromuscular disorder	□	□			□ Yes □ No
Obesity	□	□			□ Yes □ No
Obsessive compulsive disorder	□	□			□ Yes □ No
Personality disorder	□	□			□ Yes □ No
Pervasive developmental disorder	□	□			□ Yes □ No
Reading difficulty	□	□			□ Yes □ No
Respiratory condition	□	□			□ Yes □ No
Rett’s syndrome	□	□			□ Yes □ No
Schizophrenia	□	□			□ Yes □ No
Self-injuring behavior	□	□			□ Yes □ No
Seizure disorder/epilepsy	□	□			□ Yes □ No
Sickle cell anemia/ thalassemia/other hereditary anemias	□	□			□ Yes □ No
Sleep disorder	□	□			□ Yes □ No
Speech problem	□	□			□ Yes □ No
Suicide attempt	□	□			□ Yes □ No
Tuberous sclerosis	□	□			□ Yes □ No
Vision impairment	□	□			□ Yes □ No
Other: Specify condition	□	□			□ Yes □ No
1.	□	□			□ Yes □ No
2.	□	□			□ Yes □ No
3.	□	□			□ Yes □ No
4.	□	□			□ Yes □ No
5.	□	□			□ Yes □ No

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