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Registration

NIKADE is going to perform a study on 3-10 year old children with ASD. If you would like to join the project, please fill out the form below:

Child’s first and last name

Child’s birth date

Father’s first and last name

Mother’s first and last name

Phone number

Emergency phone number

Address

Is child’s mother tongue Persian?

Yes

Does he/she have a history of head trauma?

Yes

Does he/she have a history of neurological disease and disorders?

Yes

Does he/she have claustrophobia?

Yes

Does he/she use metal implants?

Yes

Is there any history of hereditary disease such as fragile X syndrome in the family?

Yes

Does he /she have history of suicide?

Yes

Does he/she suffer any kind of visual or auditory problems, which leads to impairment in communication?

Yes

Does he/she have a history of endocrinopathy?

Yes

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