Register someone in your care for the Genetics and Microbiology Research Project 2

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Your Name and Email address
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Details of the Person in your Care
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female male
Yes No Why do we ask this?
New Zealand European Chinese Latin American Middle Eastern
Maori Indian African American Other European
Pacific Islander Japanese African
Australian Korean American
Australian Aboriginal Other Asian Other
Details of the Condition of the Person in your Care
Autism spectrum disorder
Asperger syndrome
Other neurodevelopmental disorder
My dependent has not been diagnosed with ASD or neurodevelopmental disorder
No
Yes
Don't know
Don't want to say
Yes No Don't know or don't want to say
No Don't want to say Yes, my dependent has been diagnosed with: (check all that apply)
Attention-deficit hyperactivity disorder Fragile X syndrome Dyslexia
Bipolar disorder Prader-Willi syndrome Dyspraxia
Depression or Anxiety Turner syndrome Epilepsy
Obsessive-compulsive disorder Tuberous sclerosis Migraine
Other neurological disorders Tourette syndrome Down syndrome
Gastrointestinal disorder Williams syndrome Rett syndrome
Details of your Dependent's Family Members
No Don't know Don't want to say
Yes, my dependent has one or more parents with: (check all that apply)
Autism spectrum disorder Asperger syndrome
Attention-deficit hyperactivity disorder Fragile X syndrome Dyslexia
Bipolar disorder Prader-Willi syndrome Dyspraxia
Depression or Anxiety Turner syndrome Epilepsy
Obsessive-compulsive disorder Tuberous sclerosis Migraine
Other neurological disorders Tourette syndrome Down syndrome
Gastrointestinal disorder Williams syndrome Rett syndrome
Yes, my dependent has one or more siblings with: (check all that apply)
Autism spectrum disorder Asperger syndrome
Attention-deficit hyperactivity disorder Fragile X syndrome Dyslexia
Bipolar disorder Prader-Willi syndrome Dyspraxia
Depression or Anxiety Turner syndrome Epilepsy
Obsessive-compulsive disorder Tuberous sclerosis Migraine
Other neurological disorders Tourette syndrome Down syndrome
Gastrointestinal disorder Williams syndrome Rett syndrome
Yes, my dependent has one or more children with: (check all that apply)
Autism spectrum disorder Asperger syndrome
Attention-deficit hyperactivity disorder Fragile X syndrome Dyslexia
Bipolar disorder Prader-Willi syndrome Dyspraxia
Depression or Anxiety Turner syndrome Epilepsy
Obsessive-compulsive disorder Tuberous sclerosis Migraine
Other neurological disorders Tourette syndrome Down syndrome
Gastrointestinal disorder Williams syndrome Rett syndrome
Would you like to stay in touch?
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