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Canadian ASD Alliance

 
Over the last few days, there has been considerable news about the risk of having a child with autism being related to the age of the father. AutismOntario and ASD-CARC are working together to poll our website visitors to see whether this is the case or not. We hope you will help us by completing this quick survey and spreading the word to both your friends with and without a child with an autism spectrum disorder. We will display the results starting the week of September 15, 2006.
* Do you have a child or children with an autism spectrum disorder? Yes
No
* Do you have an autism spectrum disorder and no children? If yes, please complete this form from your parents' perspective, listing the dates of birth for you, your siblings, and parents. Yes
No

FIRST BORN CHILD

Date of Birth:
Day:
Month:
Year:
Sex of child Male
Female
Person completing this survey? Yes
No
Diagnosis (select all that apply):
Neurotypical
ASD
Autism
Asperger's
PDD
PDD-NOS
ADHD
Down syndrome
Other
Please Specify:

SECOND BORN CHILD

Date of Birth:
Day:
Month:
Year:
Sex of child Male
Female
Person completing this survey? Yes
No
Diagnosis (select all that apply):
Neurotypical
ASD
Autism
Asperger's
PDD
PDD-NOS
ADHD
Down syndrome
Other
Please Specify:

THIRD BORN CHILD

Date of Birth:
Day:
Month:
Year:
Sex of child Male
Female
Person completing this survey? Yes
No
Diagnosis (select all that apply):
Neurotypical
ASD
Autism
Asperger's
PDD
PDD-NOS
ADHD
Down syndrome
Other
If Other diagnosis, Please Specify:

FOURTH BORN CHILD

Date of Birth:
Day:
Month:
Year:
Sex of child Male
Female
Person completing this survey? Yes
No
Diagnosis (select all that apply):
Neurotypical
ASD
Autism
Asperger's
PDD
PDD-NOS
ADHD
Down syndrome
Other
If Other diagnosis, Please Specify:

FIFTH BORN CHILD

Date of Birth:
Day:
Month:
Year:
Sex of child Male
Female
Person completing this survey? Yes
No
Diagnosis (select all that apply):
Neurotypical
ASD
Autism
Asperger's
PDD
PDD-NOS
ADHD
Down syndrome
Other

BIOLOGICAL MOTHER

Date of Birth:
Day:
Month:
Year:
Person completing this survey? Yes
No
Diagnosis (select all that apply):
Neurotypical
ASD
Autism
Asperger's
PDD
PDD-NOS
ADHD
Down syndrome
Other
Please Specify:
CURRENT RESIDENCE:
City:
Province/State:
Country:
If other country, please specify:

BIOLOGICAL FATHER

Date of Birth:
Day:
Month:
Year: