Appendix A. Survey used to gather data for this study

TLAutStudy 2 Survey

You must be a mother, and have received the MMR, Rubella or Measles Vaccine, or had the Measles or the German Measles after age 16. Please answer all questions accurately.

MOTHER:

A. Your DOB ___/___/___     Country or State you live in: ________________________

B. You received the MMR/Rubella/Measles vaccine booster(s) on _____________

(please circle one)

C. Do you have an autistic/PDD syndrome child?           Yes___ No___

D. Do you have more than one child with Autism?          Yes___ No___

E. Have you ever had measles titers measured?            Yes___ No___

If yes, enter: ____________

F. Have you ever had rubella titers measured?              Yes___ No___

If yes, enter: ____________

G. Have you received the Hepatitis B vaccine series?     Yes___ No___

Dates: ______   ______   ______

AUTISTIC CHILD (PPD, PDD NOS, Asperger's, Autistic Syndrome) (Please provide the following information for each child with the disease)

1. Date of Birth:  ___/___/___

2. Was he/she breast-fed:  Yes___  No___   If yes, how long _____

3. First MMR vaccine:  Yes___  Age____ months.  No___

4. Second MMR vaccine:  Yes___  Age____ months.  No___

5. Age of onset of autistic symptoms:   _______months

6. Do you believe your child's MMR contributed to his/her Autism?  Yes___  No___  Don't know_____

7. What other factors do you believe contributed to your child's Autism?
Genetic____   Diet____   Stress____   Medications____   Vaccines_____   Environment____   Don't know_____

8. Hepatitis B series:  Yes____ Date_____  No_____

UNAFFECTED (NON-AUTISTIC) CHILD/CHILDREN (Please answer the following questions for each non-autistic child)

1. Date of Birth: ___/___/___   Sex: ______

2. MMR vaccine:  Yes___  No___

3. Other vaccines:  completed______

If not completed, please list and explain.
Comments: (Please write long detailed notes)
Be assured that your information will be kept in strictest confidence

Thank you,

F. Edward Yazbak, MD, FAAP
E-mail: TLAutStudy@aol.com
Address: P.O. Box 770, West Falmouth, MA 02574-0770


Your Personal Data:

Name:___________________________________________
E-mail Address:___________________________________
Address:__________________________________________