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.
First Name: *
Your answer
Last Name *
Your answer
Your Date of Birth *
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Phone Number
Your answer
Email address *
Your answer
Which SSRI were you taking during pregnancy? *
Was the drug you took during your pregnancy name brand or generic? *
Required
Dosage
Your answer
Reason for the prescription? *
Your answer
What were the date(s) of prescription?
Your answer
Describe how you discovered your child's difficulties or problems:
Your answer
Have your child been diagnosed? What was the diagnosis?
Your answer
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?
Your answer
Start date of medication *
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YYYY
End date of medication *
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DD
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YYYY
Date of Child's Birth
MM
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DD
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YYYY
Check here to indicate whether an attorney can contact you about your child's injury *
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