* Denotes Required Field

Name of Infant/Child*:
Gender*:	Male  Female
Birth Date*:	(or EDD if child not yet born)
Due Date:
Birth Weight:

Was your child born before 36 weeks of gestational age?    Yes   No

Diagnosis/any other relevant history that you think we may need to know* (please select all that apply)

None  Autism Spectrum Disorder If yes, please specify  Autism  PDD-NOS  Asperger's  Rett Syndrome  Tuberous Sclerosis Complex  ADHD  Dyslexia  Learning disability If yes, please specify  Language disorder If yes, please specify  Epilepsy  Sleep Disorder  Other

Does your child have any known genetic conditions?   Yes  No

If yes, please specify

Add Additional Children

Parent/Guardian Name*:
Street Address*:
City, State*:
Zip Code*:
Email Address:
Telephone:
If you and/or your significant other would like to be contacted for adult research opportunities in our lab, please include your names and birthdates as well.
How did you hear about us?*
Autism Spectrum Center  Developmental Medicine Center  Department of Neurology  Facebook Developmental Medicine Facebook Page Neurology Facebook Page  Friend/referral  Online Search  Other

Ethnicity (Optional)

Hispanic or Latino Non Hispanic or Non-Latino

Race (Optional)

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White or Caucasian