Antidepressants and Autism Questionnaire
Please complete this form if you took SSRI antidepressants while pregnant and have one or more children with ASD.  If you have more than one child with an ASD, please complete for each child/pregnancy.  Thank you.
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First Name: *
Last Name *
Your Date of Birth *
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Phone Number
Email address *
Was the drug you took during your pregnancy name brand or generic? *
Required
Which SSRI/SNRI were you taking during pregnancy? *
Required
Dosage
Reason for the prescription (if depression, please state mild, moderate, severe, etc.)? *
What were the date(s) of prescription?
Describe how you discovered your child's difficulties or problems:
Have your child been diagnosed?  What was the diagnosis?
What stage(s) of pregnancy did you take SSRIs? *
Required
What was your State of residence while pregnant? *
Where were you living during your pregnancy?
Start date of medication
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End date of medication
MM
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Date of Child's Birth
MM
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YYYY
Check here to indicate whether an attorney from the firm can contact you about your child's injury for a free consultation. *
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This form was created inside of Nidel & Nace, PLLC.