Si prefiere realizar esta encuesta en español, haga clic aquí. Yes
No
E-mail
* must provide value
How many languages are spoken at home?
1 More than 1
Primary language spoken at home?
English Spanish ASL / Sign Language Arabic Bengali Chinese Farsi French German Hebrew Hindi Italian Japanese Korean Portuguese Punjabi/Lahnda Russian Tagalog Thai Vietnamese Other
Percent time speaking ______ ?
Secondary language spoken at home?
English Spanish ASL / Sign Language Arabic Bengali Chinese Farsi French German Hebrew Hindi Italian Japanese Korean Portuguese Punjabi/Lahnda Russian Tagalog Thai Vietnamese Other
Percent time speaking ______ ?
Baby's Date of Birth
* must provide value
Y-M-D
Baby's Current Age in Days:
View equation Please change baby's birthdate if the age is incorrect.
United States of America Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bougainville Brazil British Indian Ocean British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Islands Cayman Islands Central African Republic Chad Chile China (Mainland) China (Taiwan) Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City State) Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts & Nevis Saint Lucia Saint Martin Saint Pierre & Miquelon Saint Vincent Samoa San Marino Sao Tomé & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Islands Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of GB & NI Uruguay US Virgin Islands Uzbekistan Vanuatu Venezuela Vietnam Wallis & Futuna Islands Yemen Zambia Zimbabwe
Female
Male
Baby's Birth Weight (lbs.ounces)
e.g. 6.15 for 6 lbs, 15 ounces.
Baby's Birth Weight (kilograms)
kg
Baby's Race, Ethnicity, or Origin
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish Origin
Native Hawaiian or Other Pacific Islander
Middle Eastern or North African
White
Other (please specify)
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish Origin
Native Hawaiian or Other Pacific Islander
Middle Eastern or North African
White
Other (please specify)
Note: You may report more than one group.
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55+
years
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55+
years
Less than High School High School Graduate Some College, Trade School, or Associates Degree College Graduate (Bachelors) Graduate School Not Sure/Unknown
Less than High School High School Graduate Some College, Trade School, or Associates Degree College Graduate (Bachelors) Graduate School Not Sure/Unknown
Current Marital Status of Mother:
Married Separated Widowed Divorced Never Married Not Sure/Unknown
Was baby a single birth, twin, triplet, or more?
Single
Twin
Triplet
Quads or more
Single
Twin
Triplet
Quads or more
Is baby adopted or in foster care/temporary custody?
Yes
No
How many older full siblings does baby have?
0 1 2 3 4 5 6 7 8 9 10+
How many older half-siblings does baby have?
0 1 2 3 4 5 6 7 8 9 10+
Baby's total number of older siblings:
View equation Are any of the following family members Deaf or have moderate-to-severe hearing loss?
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Select none or multiple if applicable.
Do any of the following family members have a diagnosis of Autism Spectrum Disorder?
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Select none or multiple if applicable.
Was the autism diagnosis related to a genetic mutation such as fragile X or 22q11.2 deletion syndrome?
Yes
No
Did any of the following family members have a history of developmental delay while an infant?
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Select none or multiple if applicable.
Do any of the following family members have a diagnosis of Schizophrenia or Bipolar Disorder?
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Baby
Mother
Father
Brother
Sister
Half-Brother
Half-Sister
Other (please specify)
Select none or multiple if applicable.
Was your baby conceived with the help of assisted reproductive technology (ART) such as IVF, IUI, etc...?
Yes
No
Which ART methods assisted you in conceiving baby?
In vitro fertilization (IVF)
Intrauterine insemination (IUI)
Intracytoplasmic sperm injection (ICSI)
Egg donation
Sperm donation
Embryo adoption
Other (please specify)
In vitro fertilization (IVF)
Intrauterine insemination (IUI)
Intracytoplasmic sperm injection (ICSI)
Egg donation
Sperm donation
Embryo adoption
Other (please specify)
Select multiple if appropriate.
Were there any of the following interventions, complications, or abnormalities during this pregnancy with baby?
Gestational diabetes
Infections requiring antibiotics
Placenta previa
Placenta accreta
Chorioamnionitis
Hyperemesis gravidarum
Antidepressants to treat depression
Anticonvulsants to treat seizures
Intrauterine growth restriction (IUGR)
Preeclampsia/eclampsia
Anemia
Hypertension (high blood pressure)
History of recurrent miscarriage/ recurrent pregnancy loss
Preterm labor
Cerclage, cervical incompetence, or insufficiency
Placental abruption
Vaginal bleeding
Treatment with opioids including Subutex (buprenorphine), suboxone, methadone
Perinatal or Post-partum depression
Perinatal or Post-partum psychosis
Other (please specify)
Gestational diabetes
Infections requiring antibiotics
Placenta previa
Placenta accreta
Chorioamnionitis
Hyperemesis gravidarum
Antidepressants to treat depression
Anticonvulsants to treat seizures
Intrauterine growth restriction (IUGR)
Preeclampsia/eclampsia
Anemia
Hypertension (high blood pressure)
History of recurrent miscarriage/ recurrent pregnancy loss
Preterm labor
Cerclage, cervical incompetence, or insufficiency
Placental abruption
Vaginal bleeding
Treatment with opioids including Subutex (buprenorphine), suboxone, methadone
Perinatal or Post-partum depression
Perinatal or Post-partum psychosis
Other (please specify)
Select none or multiple if applicable.
Did mother experience any extremely stressful event during pregnancy, such as the death of a family member, divorce, homelessness, living in a war zone, or abuse?
Yes
No
If you feel comfortable doing so, please check which of the following categories you would classify the stressful event. Your answers are all voluntary.
sexual abuse or assault
physical abuse or assault
emotional abuse or psychological maltreatment
neglect
serious accident, illness, or medical procedure
victim or witness of domestic violence
victim or witness to community violence
school violence
bullying
natural or manmade disasters
forced displacement
terrorism, or political violence
military trauma (deployment)
victim or witness to extreme personal or interpersonal violence
traumatic grief or separation (such as a death in the family)
other (please briefly specify)
sexual abuse or assault
physical abuse or assault
emotional abuse or psychological maltreatment
neglect
serious accident, illness, or medical procedure
victim or witness of domestic violence
victim or witness to community violence
school violence
bullying
natural or manmade disasters
forced displacement
terrorism, or political violence
military trauma (deployment)
victim or witness to extreme personal or interpersonal violence
traumatic grief or separation (such as a death in the family)
other (please briefly specify)
Note: this is optional. If you would like, please describe briefly the category of incident of the stressful event.
Other - please briefly specify how you would categorize your traumatic event(s).
This is optional and confidential.
Has mother had any of the following diagnoses, before, during, or after pregnancy?
depression
anxiety
obsessive compulsive disorder
bipolar disorder
ADHD
psychosis, schizophrenia, or schizoaffective disorder
Other
depression
anxiety
obsessive compulsive disorder
bipolar disorder
ADHD
psychosis, schizophrenia, or schizoaffective disorder
Other
Did mother have a fever (>101F, 38.3C) during pregnancy?
Yes
No
During which trimester was mother's fever?
First trimester (weeks 1-12)
Second trimester (weeks 13-27)
Third Trimester (weeks 28-40)
First trimester (weeks 1-12)
Second trimester (weeks 13-27)
Third Trimester (weeks 28-40)
Select Multiple if Appropriate
Was mother infected with COVID-19 either before or during pregnancy?
Yes
No
When was mother diagnosed with COVID-19?
M-D-Y
Did mother receive a vaccine for COVID-19?
Yes No
Which COVID-19 vaccine did mother receive?
Moderna Oxford/AstraZeneca Pfizer/BioNTech Janssen (Johnson & Johnson) Serum Institute of India. Covishield (Oxford/AstraZeneca formulation) Sinopharm (Beijing) Sinovac/CoronaVac Sputnik V Other
When was mother vaccinated against COVID-19?
M-D-Y
Was baby ever diagnosed with COVID-19?
Yes No
When was baby diagnosed with COVID-19?
M-D-Y
Did either of baby's parents perform agricultural farm work either just before or during the pregnancy?
Yes
No
Was mother in close contact with herbicides or pesticides?
Yes
No
Was father in close contact with herbicides or pesticides?
Yes
No
Did mother ever use any of the following substances during pregnancy?
Tobacco (cigarettes, cigars)
Vaping (e-cigarettes)
Alcohol
Cannabis (e.g. medicinal marijuana)
Stimulants (e.g. cocaine, amphetamines)
Opioids (e.g. fentanyl, heroin)
Hallucinogenic (e.g. LSD, mushrooms)
Other (please specify)
Tobacco (cigarettes, cigars)
Vaping (e-cigarettes)
Alcohol
Cannabis (e.g. medicinal marijuana)
Stimulants (e.g. cocaine, amphetamines)
Opioids (e.g. fentanyl, heroin)
Hallucinogenic (e.g. LSD, mushrooms)
Other (please specify)
Please select the appropriate category even if the specific substance isn't listed (e.g. select "Stimulants" for crack or meth).
Other substance (please specify):
How many weeks was mother's pregnancy with baby? (usually 37-42 weeks)
22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43+
How was your baby delivered?
Unassisted Vaginal Birth Assisted Vaginal Birth (forceps, vacuum) Planned Caesarean Emergency Caesarean
How many total live births has mother had, including your baby?
1 2 3 4 5 6 7 8 9 10+
How many total pregnancies has mother had, including your baby?
1 2 3 4 5 6 7 8 9 10+
How often does your baby cry?
Never/Rarely
Sometimes
Often
Never/Rarely
Sometimes
Often
Does your baby cry three or more hours per day, for at least three days per week, for at least three weeks?
Yes
No
Was your baby hospitalized in the Neonatal Intensive Care Unit (NICU) following delivery?
Yes
No
Also called special-care baby units (SCBU).
How many days did your baby stay in the NICU?
Has your baby had any of the following diagnoses or procedures?
Seizure
Stroke
Motor delay
Intracranial hemorrhage
Hypoxic ischemic encephalopathy requiring cooling
Extracorporeal membrane oxygenation (ECMO)
Perinatal asphyxia
Acid reflux
Infant respiratory distress syndrome
Jaundice
Colic
Down syndrome
Failure to thrive
Tic disorder
Head injury, brain tumor, cortical dysplasia
Cardiac disorder
Recurrent ear infections
Surgery requiring general anesthesia
Re-hospitalization following initial hospital discharge
Small for gestational age
Low birthweight
Brain damage
Cerebral palsy
Cochlear implant
Other (please specify)
Seizure
Stroke
Motor delay
Intracranial hemorrhage
Hypoxic ischemic encephalopathy requiring cooling
Extracorporeal membrane oxygenation (ECMO)
Perinatal asphyxia
Acid reflux
Infant respiratory distress syndrome
Jaundice
Colic
Down syndrome
Failure to thrive
Tic disorder
Head injury, brain tumor, cortical dysplasia
Cardiac disorder
Recurrent ear infections
Surgery requiring general anesthesia
Re-hospitalization following initial hospital discharge
Small for gestational age
Low birthweight
Brain damage
Cerebral palsy
Cochlear implant
Other (please specify)
Is baby currently taking any prescription medication?
Yes
No
Please describe which prescription medications baby takes, and why.
Which of the following behaviors does your baby do regularly?
Makes eye contact
Responds to own name
Smiles socially
Stares into space/fixates on objects
Flaps hands or arms, bangs or shakes head repeatedly
Points or waves goodbye
Difficult to soothe when upset
Poor sleeper (difficulty in falling and staying asleep, poor napping, reduced total sleep for age)
Sensitive to sensory stimuli: crying in response to loud noises, clothing textures, food textures, changes in temperature, face wiping, dirty hands, sunlight in face, etc
Imitates your movements, vocal, or facial expressions
Follows things with eyes and recognizes people at a distance
Makes noises to get your attention
Notices or cares if you hurt yourself or are discontented
Reaches for toys
Rolls onto back
Coos, makes gurgling sounds
Turns head toward sounds
Can briefly calm herself (may bring hands to mouth and suck on hand)
Begins to act bored (cries, fussy) if activity doesn't change
Can hold head up and begins to push up when lying on tummy
Pays attention to faces
Tries to look at parent
Makes eye contact
Responds to own name
Smiles socially
Stares into space/fixates on objects
Flaps hands or arms, bangs or shakes head repeatedly
Points or waves goodbye
Difficult to soothe when upset
Poor sleeper (difficulty in falling and staying asleep, poor napping, reduced total sleep for age)
Sensitive to sensory stimuli: crying in response to loud noises, clothing textures, food textures, changes in temperature, face wiping, dirty hands, sunlight in face, etc
Imitates your movements, vocal, or facial expressions
Follows things with eyes and recognizes people at a distance
Makes noises to get your attention
Notices or cares if you hurt yourself or are discontented
Reaches for toys
Rolls onto back
Coos, makes gurgling sounds
Turns head toward sounds
Can briefly calm herself (may bring hands to mouth and suck on hand)
Begins to act bored (cries, fussy) if activity doesn't change
Can hold head up and begins to push up when lying on tummy
Pays attention to faces
Tries to look at parent
Has your child lost any skills (movement, language, etc...) that they once had?
Yes
No
Please describe the lost skills, and when this occurred.
Did mother try to breastfeed, even if it didn't work out?
Yes
No
How has baby been fed up until now?
All formula Mostly formula Mostly breastmilk All breastmilk Other (please specify)
Does your baby have any quirky, odd, or unusual behaviors?
Yes
No
Please describe the unusual behaviors your baby has.
Do you have any other concerns about your baby's development?
Submit
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