Appendix A for Adverse Outcomes Associated with Postpartum Rubella or MMR Vaccine

Appendix A. 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 booster(s) on _____________

(please circle one)

C. Do you have an autistic/PDD syndrome child? Yes___ No___

D. Do you have more than one child with Autism? Yes___ No___

E. Have you ever had measles titers measured? Yes___ No___

If yes, enter: ____________

F. Have you ever had rubella titers measured? Yes___ No___

If yes, enter: ____________

G. Have you received the Hepatitis B vaccine series? Yes___ No___

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: Yes___ No___ 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?

Yes___No___Don't know_____

7. What other factors do you believe contributed to your child's Autism?

Genetic____ Diet____ Stress____ Medications____ Vaccines_____

Environment____ 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: Yes___ No___

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:___________________________________
Address:__________________________________________