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Are you filling this out to express interest in research participation in San Diego in July 2022 when our Fragile X Center is visiting for the International Fragile X Meeting?
Yes
No
The purpose of this study is to create a repository, or storage area, of biological samples (such as blood), cognitive and behavioral data (such as IQ testing), and neurophysiological data (such as EEG) from typically developing individuals as well as individuals with Fragile X Syndrome, Autism Spectrum Disorder, and other developmental disabilities.
Thank you for your interest in participating in research! We are excited you are interested in joining us in San Diego!
Your First and Last Name
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Communication Preference
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Phone Number
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Email Address
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State
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Zip Code
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Are you completing this survey for yourself or on behalf of someone else?
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Myself
Someone else
What is their relation to you?
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My child My sibling My partner Other
If "Other", please describe:
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Please complete the following information with regard to that person:
First Name
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Last Name
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Date of Birth
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Today M-D-Y MM-DD-YYYY
View equation calculates age today
Gender
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Male Female Transgender Male Transgender Female Non-binary Choose not to disclose Other
Do you have any history of a developmental disorder? (for example: Fragile X Syndrome, Autism, Down Syndrome, intellectual disability, genetic disorder, etc.)
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Yes
No
Does ______ have any history of a developmental disorder? (for example: Fragile X Syndrome, Autism Spectrum Disorder, Down Syndrome, intellectual disability, genetic disorder, etc.)
* must provide value
Yes
No
Do you have Fragile X Syndrome?
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Yes
No
Does ______ have Fragile X Syndrome?
* must provide value
Yes
No
Do you have Autism Spectrum Disorder (ASD)
* must provide value
Yes
No
Does ______ have Autism Spectrum Disorder?
* must provide value
Yes
No
Do you have any other diagnoses of developmental or genetic disorders?
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Yes
No
Does ______ have any other diagnoses of developmental or genetic disorders?
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Yes
No
Please specify developmental disorder and/or genetic disorder
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Please specify developmental and/or genetic disorder:
If known, what was your most recent IQ score?
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86 or higher
71-85
55-70
Below 55
I don't know/I don't have an IQ test result
If known, what was ______ 's most recent IQ score?
* must provide value
86 or higher
71-85
55-70
Below 55
I don't know/I don't have an IQ test result
Do you have any immediate biological relatives with autism spectrum disorder (ASD) or any other developmental disorders?
* must provide value
Yes
No
Does ______ have any immediate biological relatives with autism spectrum disorder (ASD) or any other developmental disorders?
* must provide value
Yes
No
What is their relation to you? (select all that apply)
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What is their relation to ______ ? (select all that apply)
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Do you have any history of developmental or language delays?
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Yes
No
Does ______ have any history of developmental or language delays?
* must provide value
Yes
No
Do you have any history of epilepsy or seizures?
* must provide value
Yes
No
Does ______ have any history of epilepsy or seizures?
* must provide value
Yes
No
Do you have any history of concussions or head trauma?
* must provide value
Yes
No
Does ______ have any history of concussions or head trauma?
* must provide value
Yes
No
Do you have any auditory or visual impairments that cannot be corrected?
* must provide value
Yes
No
Does ______ have any auditory or visual impairments that cannot be corrected?
* must provide value
Yes
No
Do you have a history or diagnosis of any psychiatric conditions?
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Yes
No
Does ______ have a history or diagnosis of any psychiatric conditions?
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Yes
No
Please select all that apply:
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If "Other", please describe:
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Do you have any other diagnosed medical conditions?
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Yes
No
Does ______ have any other diagnosed medical conditions?
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Yes
No
Please list the diagnosed medical condition(s):
Do you take any prescribed medications?
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Yes
No
Does ______ take any prescribed medications?
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Yes
No
Please list any prescribed medication(s):
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Have there been any changes to the prescribed medication(s) within the past month?
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Yes
No
Do you have any implanted medical devices or metal in the body (pacemaker, braces, pins/screws, etc.)?
* must provide value
Yes
No
Does ______ have any implanted medical devices or metal in the body (pacemaker, braces, pins/screws, etc.)?
* must provide value
Yes
No
What is the primary language you speak at home?
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English
Spanish
Mandarin
Cantonese
Tagalog
Vietnamese
French or French Creole
Arabic
Korean
Russian
German
Other
If "Other", please describe
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Which is your dominant hand (writing, throwing, using scissors, etc.)?
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Right Hand
Left Hand
Ambidextrous
Which is ______ 's dominant hand (writing, throwing, using scissors, etc.)?
* must provide value
Right Hand
Left Hand
Ambidextrous
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