This survey compiles information about children suffering from long term disabilities acquired since birth and the vaccinations, such as MMR, that they may have received.
The information gathered will be used to investigate the causes of childhood disabilities.
This survey is sponsored by JABS, and is managed independently on their behalf by Datasmith.
Vaccinated children with disabilities survey

Please complete the following form for one of your children, irrespective of his or her current health.
If you have other children, please complete another of these forms after you have submitted this one.
If you need to change details later, please simply submit a new form for the same child.
The information you provide will remain confidential.
Your answers to the first four questions will help us to confirm your information and to contact you if needed
Your e-mail address (or 'phone number if no email)
Your name
Your postcode
Country
Please tell us a little about your child and his or her birth
Child's name
Date of birth
 dd/mm/yyyy
Child's gender
Number of weeks gestation - or weeks early / late
 weeks... gestation , early , or late
Mother's age at child's birth
Any problems during pregnancy, at birth or soon after
Mother's vaccinations (with dates)
during pregnancy and immediately after birth
Please describe any dental treatment
during pregnancy or while breast-feeding
Does this child have any of the following serious, long-term problems?
Please enter the age of the child in months or years and months when the type of problem first appeared, or leave blank. Need help to calculate age in months? Click here.
Autism

Autism, Aspergers, Pervasive Developmental disorder (PDD), Semantic Pragmatic disorder (SPD)		 Stomach/gut problems

Crohn's, Irritable Bowel disorder (IBD), Diabetes, Bowel problems		 Neurological Problems

Seizures, Fits, Encaphelitis, Epilepsy, Meningitis		 Developmental problems

Learning difficulties, Language, Behaviour, ADHD (hyperactivity)		 Allergies/immunity problems

Asthma, severe allergies, Acquired Immune Deficiency (AID), diet problems		 Mobility problems

Arthritis,Paralysis, Dispraxia, hearing, eyesight, walking
Any problems not mentioned above?

Any related family illnesses or reactions?
Has this child ever had any of the following childhood diseases?
Please enter the age of the child in months when he or she had the disease, or leave blank. Need help to calculate age in months? Click here.
Measles

 Mumps

Rubella

 Diphtheria

 Meningitis

 Polio

 Whooping cough
 Chickenpox
 Gastroenteritis
Please give details of the vaccines given to this child.
Please enter the age of the child in months when he or she had the vaccine, or leave blank. If you're not sure of the age, approximations will do! Need help to calculate age in months? Click here.
Vaccine
First Jab
Second jab
Third Jab
Booster
Please briefly describe any illnesses, symptoms, treatment etc experienced at about the time of the jab, and the number of days between jab and the problem.
MMR
Measles, Mumps Rubella
days
MR
Measles Rubella
     
days
Measles Single vaccine
     
days
Mumps Single vaccine
     
days
Rubella Single vaccine
     
days
DT Diphtheria Tetanus
days
DTP DT plus Whooping cough
days
DTPH DTP plus Hib Meningitis
 
days
DTaP Another type of DTP
days
Polio
days
Meningitis C
 
days
Hib Haemophilus influenzae b
 
days
HepB Hepatitis B
 
days
BCG TB
     
days
Other Please enter vaccine
days
Please describe the story of your child's disability, its origins, and his or her general health

If we have missed anything important on this form, please describe it here (in not more than 150 words).
 

Thank you for completing this questionnaire. If you want to keep a copy, print (landscape) or save this page now!

All the information given here will be used only for the compilation of statistics and to provide de-personalised illustrations: everything personal will be kept strictly confidential.
Your details are used solely by us to verify your data with you, and to contact you if we have any follow-up query.
This questionnaire is managed within the rules set out by UK Data Protection regulations, which gives you rights over the data you enter here.
Nothing in this document is intended as, or should be construed as, medical advice or opinion.


















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