Pre-Screening Questionnaire

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Hi and welcome to the Developmental Neuroscience Lab at UCSD (Link: https://dnlab.ucsd.edu)! We are looking for kids at 3-4 year old both neurotypical and with Autism Spectrum Disorder. If you are locally available at San Diego and are interested in participating in our study with your child, please fill out the below survey and we will reach out to you shortly!

Your name *

Your relation to the child *

Parent

Sibling

Caregiver

Teacher

Other

Email *

Phone Number *

Is your child at the age of 3 to 4? *

Yes

No (Sorry you are not eligible for the study!)

Maybe

Sex of your child *

Male

Female

Other

Prefer not to say

Does your child have Autism Spectrum Disorder? *

Yes

Do you have documentations of the diagnosis? *

Yes

Not sure

If your child is diagnosed with ASD, do they have any below condition? *

History of seizures

Brain injury

Neurological disorders

Concurrent psychiatric condition (other than ASD)

None of the above

My child does not have Autism Spectrum Disorder.

Required

If no, does your child have any below condition? *

History of seizures

Brain injury

Neurological disorders

Concurrent psychiatric condition (other than ASD)

An immediate family history of ASD

Currently taking any psychoactive medications

None of the above

My child has Autism Spectrum Disorder.

Required

Are you and your child available coming to UCSD in San Diego for two sessions (each lasting about 1 hour) within the next 2 months? *

Yes

Maybe / Not sure

Any questions or concerns? (You can also reach out to us at xil239@ucsd.edu)

Submit

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