Questionaire Packets

StudyID #: __________________

AUTOIMMUNE DISEASE SURVEY

R

Form Approved

OMB NO. __________

Exp. Date __________

espondent (Please indicate your relationship to study child):

□ Biological Mother □ Biological Father □ Step Mother □ Step Father □ Maternal Grandparent

□ Paternal Grandparent □ Other: Specify ___________________

Instructions: An autoimmune condition occurs when the body produces a substance (antibodies) against itself that can damage parts of the body. Please indicate if any biological (related by birth) members of your family have any of these autoimmune conditions by placing a  in the appropriate columns below. The family members we are interested in are the biological mother and biological father of the study child, the study child, and the biological brothers and sisters (including half brothers and sisters) of study child. If a family member has one of the conditions, please provide the age at which a diagnosis was first made underneath the box. If none of your family members have the conditions please check the box in the “None” column. If you are uncertain about the meaning of any of the conditions, please use the attached glossary. If you are still uncertain, please mark the box in the “Don’t Know” column and someone will go over it with you at another time.

It is important for us to be able to verify the birth order of the siblings as well as the relationship of each of the siblings to the study child. In the space below please indicate in order of oldest to youngest the sex, date of birth and relationship of each sibling to child. NOTE: 1= OLDEST, 6= YOUNGEST

Sibling	Date of birth (MM/DD/YYYY)	Sex	Relationship to Study Child
1		□ Male □ Female	□ Full sibling □ Half sibling
2		□ Male □ Female	□ Full sibling □ Half sibling
3		□ Male □ Female	□ Full sibling □ Half sibling
4		□ Male □ Female	□ Full sibling □ Half sibling
5		□ Male □ Female	□ Full sibling □ Half sibling
6		□ Male □ Female	□ Full sibling □ Half sibling

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Disease	Mother	Father	CHILD	Siblings 1 2 3 4 5 6	None	Don’t Know
Addison’s Disease	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Aplastic Anemia	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Ankylosing Spondylitis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Asthma	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Autoimmune hepatitis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Celiac Disease	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Crohn’s Disease	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Dermatitis herpetiformis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Diabetes	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Use insulin	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Not on insulin	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Disease	Mother	Father	CHILD	Siblings 1 2 3 4 5 6	None	Don’t Know
Gestational diabetes only	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Eczema/psoriasis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Giant cell arteritis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Graves Disease	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Guillain-Barre Syndrome	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Hashimoto thyroiditis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Hemolytic Anemia	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Hypothyroidism	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Hyperthyroidism	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Irritable bowel syndrome	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Migraine Headaches	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Disease	Mother	Father	CHILD	Siblings 1 2 3 4 5 6	None	Don’t Know
Mixed connective tissue disease	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Multiple sclerosis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Myasthenia Gravis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Narcolepsy	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Optic neuritis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Pemphigus	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Reiter’s Syndrome	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Rheumatoid Arthritis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Scleroderma (progressive systemic sclerosis, CREST)	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Sjogren’s syndrome	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Stevens-Johnson syndrome	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Disease	Mother	Father	CHILD	Siblings 1 2 3 4 5 6	None	Don’t Know
Sydenham’s chorea	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Systemic lupus erythematosus (SLE)	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Thrombocytopenia (immune, idiopathic)	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Tourette’s syndrome	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Ulcerative colitis	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
Other. Specify condition	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
1.	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
2.	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
3.	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□
4.	□ ------	□ ------	□ ------	□ □ □ □ □ □ ----- ----- ----- ----- ----- -----	□	□

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