Acetaminophen (Tylenol) 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 or ADHD? 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 or ADHD (i.e. both parents, father only, mother only, legal guardian).

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

Did you (mother) take Tylenol or acetaminophen while you were pregnant?

Do you have medical records confirming Tylenol or acetaminophen usage during your pregnancy?

Do you have receipts of purchase of Tylenol or acetaminophen during your pregnancy?

Do you currently have your child with autism or ADHD 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)?

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 the mother’s primary residence during pregnancy:

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

Please identify the name and location of the facility where your child with autism or ADHD was born:

How was your child with autism or ADHD delivered? (c-section, vaginal, etc.) Were there any complications? (for example, NICU care, etc.):

Has your child been diagnosed with autism or ADHD (either formally or informally)?

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

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

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

Please list all medical prescriptions written for your child with autism or ADHD 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:

If your child with autism or ADHD was given Tylenol or acetaminophen between birth and age three, how often was it given? Which doctor prescribed or recommended the medication?