Parent Name:
* must provide value
Best Phone Number:
* must provide value
Best e-mail address:
* must provide value
Mailing Address:
* must provide value
Preferred forms of contact:
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Please check all that apply.
Does a parent speak and understand English?
* must provide value
Yes
No
Prefer not to answer
If not, what languages would you feel comfortable speaking during your appointment?
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Child Name:
* must provide value
Child Date of Birth:
* must provide value
Today M-D-Y
Child's Gender/Sex
* must provide value
Female
Male
Prefer not to answer
Where does your child go to school?
* must provide value
What grade level is your child in?
* must provide value
Was your child adopted?
* must provide value
Yes
No
Prefer not to answer
At what age was your child adopted?
* must provide value
Does your child speak and understand English?
* must provide value
Yes
No
Prefer not to answer
How much did your child weigh at birth?
* must provide value
At how many weeks of gestation was your child delivered?
* must provide value
Were there any birth complications with your child?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any hearing problems?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any vision problems?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
To the best of your knowledge, is your child colorblind?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a neurological or psychiatric condition?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a learning disability?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child have any other medical diagnoses that you have not previously mentioned?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Could your child have metal in his/her body?
* must provide value
Yes
No
Prefer not to answer
Please describe.
Is there any chance that your child was exposed to drugs before they were born?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child regularly take any medications?
* must provide value
Yes
No
Prefer not to answer
Please list the medication and reason for its use (e.g. for ADHD).
Do you have a second child?
* must provide value
Yes
No
Child Name:
* must provide value
Child Date of Birth:
* must provide value
Today M-D-Y
Child's Gender/Sex
* must provide value
Female
Male
Prefer not to answer
Where does your child go to school?
* must provide value
What grade level is your child in?
Was your child adopted?
* must provide value
Yes
No
Prefer not to answer
At what age was your child adopted?
* must provide value
Does your child speak and understand English?
* must provide value
Yes
No
Prefer not to answer
How much did your child weigh at birth?
* must provide value
At how many weeks of gestation was your child delivered?
* must provide value
Were there any birth complications with your child?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any hearing problems?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any vision problems?
* must provide value
Yes
No
Prefer not to answer
To the best of your knowledge, is your child colorblind?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a neurological or psychiatric condition?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a learning disability?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child have any other medical diagnoses that you have not previously mentioned?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Could your child have metal in his/her body?
* must provide value
Yes
No
Prefer not to answer
Please describe.
Is there any chance that your child was exposed to any drugs before they were born?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child regularly take any medications?
* must provide value
Yes
No
Prefer not to answer
Please list the medication and reason for its use (e.g. for ADHD).
Do you have a third child?
* must provide value
Yes
No
Child Name:
* must provide value
Child Date of Birth:
* must provide value
Today M-D-Y
Child's Gender/Sex
* must provide value
Female
Male
Prefer not to answer
Where does your child go to school?
* must provide value
What grade level is your child in?
* must provide value
Was your child adopted?
* must provide value
Yes
No
Prefer not to answer
At what age was your child adopted?
* must provide value
Does your child speak and understand English?
* must provide value
Yes
No
Prefer not to answer
How much did your child weigh at birth?
* must provide value
At how many weeks of gestation was your child delivered?
* must provide value
Were there any birth complications with your child?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any hearing problems?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any vision problems?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
To the best of your knowledge, is your child colorblind?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a neurological or psychiatric condition?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a learning disability?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child have any other medical diagnoses that you have not previously mentioned?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Could your child have metal in his/her body?
* must provide value
Yes
No
Prefer not to answer
Please describe.
Is there any chance that your child was exposed to any drugs before they were born?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child regularly take any medications?
* must provide value
Yes
No
Prefer not to answer
Please list the medication and reason for its use (e.g. for ADHD).
Do you have a fourth child?
* must provide value
Yes
No
Child Name:
* must provide value
Child Date of Birth:
* must provide value
Today M-D-Y
Child's Gender/Sex
* must provide value
Female
Male
Prefer not to answer
Where does your child go to school?
* must provide value
What grade level is your child in?
* must provide value
Was your child adopted?
* must provide value
Yes
No
Prefer not to answer
At what age was your child adopted?
* must provide value
Does your child speak and understand English?
* must provide value
Yes
No
Prefer not to answer
How much did your child weigh at birth?
* must provide value
At how many weeks of gestation was your child delivered?
* must provide value
Were there any birth complications with your child?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any hearing problems?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
Does your child have any vision problems?
* must provide value
Yes
No
Prefer not to answer
Please Describe:
* must provide value
To the best of your knowledge, is your child colorblind?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a neurological or psychiatric condition?
* must provide value
Yes
No
Prefer not to answer
Has your child ever been diagnosed with a learning disability?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child have any other medical diagnoses that you have not previously mentioned?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Could your child have metal in his/her body?
* must provide value
Yes
No
Prefer not to answer
Please describe.
Is there any chance that your child was exposed to any drugs before they were born?
* must provide value
Yes
No
Prefer not to answer
Please Describe?
* must provide value
Does your child regularly take any medications?
* must provide value
Yes
No
Prefer not to answer
Please list the medication and reason for its use (e.g. for ADHD).
Any additional information you would like to include?
How did you hear about the study?
* must provide value
SEPTA Ad
Facebook Ad
Magazine Ad
Word of Mouth
Other
Please tell us how you heard about the study.
If your child is not eligible for this study, would you like us to share your information with other child development labs at the University of Pennsylvania?
* must provide value
Yes
No
