Toxic Baby Food Questionnaire

Please list the names and birth dates of all family members (include current age of children):

Who is the best person to contact regarding your child with autism? Please include phone number(s), home and mailing address, and email address(es).

Please identify who has legal custody and responsibility for your child with autism (i.e. both parents, father only, mother only, legal guardian).

What is the legal residency status of each parent and the child with autism in the U.S.?

What are the primary and secondary languages spoken in your home?

Please list the employment history of both parents (from date of conception of the child with autism to present day):

We have evidence that the following companies manufactured toxic and dangerous baby food. Please indicate if your child with autism ever consumed any of these products (especially prior to diagnosis):

We have evidence that the following stores in the Las Vegas area sold the toxic and dangerous baby food products. Please indicate if you purchased any of the manufactured baby products from any of the following stores:

Do you currently have any of your child with autism’s baby teeth?

Do you currently have any of your child with autism’s baby hair (such as a lock from his or her first haircut)?

Are both parents available and willing to consider participating in genetic testing?

Are you willing to allow your child with autism to participate in genetic testing?

Please describe any family history of autism and/or developmental delays (include the name of the individual, his/her relation to you, date of diagnosis, and diagnosing physician):

Please identify the address of your primary residence during pregnancy (if this differs between parents, list both):

Please list any other addresses the mother resided at for any period of time during pregnancy from conception until the date of delivery (include any travel locations for vacation/business purposes, as well the dates associated with each location):

Please list all facilities (include name and address) at which the mother received pre-natal care:

Please describe the birth history of the child with autism from conception to birth (i.e. hospital where your child with autism was born, complications, prenatal exposures to substances and medications, manner of delivery, NICU care, etc.):

Please list all medications and/or supplements consumed by the child with autism’s mother during pregnancy (i.e. any prescription medication, Tylenol, prenatals, folic acid, etc.):

When was the first time your child was diagnosed with autism? Where was the diagnosis made? By whom was the diagnosis made?

When was the most recent time your child was tested for autism, and what type of autism was diagnosed?

What are the most significant medical challenges that your child with autism experiences?

Please list all schools your child with autism has attended (include school name and years attended):

What treatment courses, therapies, special need programs has/does your child with autism attended (from birth to present day)? (i.e. ABA, Special Education, Speech Therapy, Occupational Therapy, Physical Therapy, etc.):

Please list all facilities and providers from which your child with autism received care (encompassing all medical concerns from birth to present day):

Please list all medical prescriptions written for your child with autism and all pharmacies utilized (encompassing all medical concerns from birth to present day):

Most medical providers require the last four digits of the patient’s social security number to release records. Please provide the last four digits of the mother’s and child with autism’s social security numbers: