Survey used to gather data for this study
TLAutStudy 2 Survey

You must be a mother, and have received the MMR, Rubella or Measles Vaccine, or had the Measles or the German Measles after age 16. Please answer all questions accurately.

MOTHER:
A) Your DOB:
Country or State you live in:
B) You received: the MMR
Rubella
Measles vaccine
on 
C) Do you have an autistic/PDD syndrome child? YesNo
D) Do you have more than one child with Autism? YesNo
E) Have you ever had measles titers measured? YesNo
If yes, enter:
F) Have you ever had rubella titers measured? YesNo
If yes, enter:
G) Have you received the Hepatitis B vaccine series? YesNo
Dates:

AUTISTIC CHILD (PPD, PDD NOS, Asperger's, Autistic Syndrome)
(Please provide the following information for each child with the disease)

1) Date of Birth:
2) Was he/she breast-fed: YesNo
If yes, how long:
3) First MMR vaccine: Yes  Age months. No
4) Second MMR vaccine: Yes  Age months. No
5) Age of onset of autistic symptoms: months
6) Do you believe your child's MMR contributed to his/her Autism? YesNoDon't know
7) What other factors do you believe contributed to your child's Autism?
Genetic
Diet
Stress
Medications
Vaccines
Environment
Other
Don't know
8) Hepatitis B series: Yes  Date  No

UNAFFECTED (NON-AUTISTIC) CHILD/CHILDREN
(Please answer the following questions for each non-autistic child)

>>
1) Date of Birth & Sex
2) MMR vaccine: YesNo
3) Other vaccines: completed
If not completed, please list and explain.
Comments: (Please write long detailed notes):

Be assured that your information will be kept in strictest confidence.

Thank you

F. Edward Yazbak, MD, FAAP
E-mail: TLAutStudy@aol.com
Address: P.O. Box 770, West Falmouth, MA 02574-0770

Your Personal Data:
Name:
E-mail:
Address:
Other information you wish to share with us: