Autistic Spectrum Disorder Questionnaire Please fill out the following questionnaire. Please include copies of any lab tests that have been run
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1 Autistic Spectrum Disorder Questionnaire Please fill out the following questionnaire. Please include copies of any lab tests that have been run Name (child) Age Height Weight Date of birth Parents names Diagnosis Address Blood Type Phone numbers address Age autism symptoms first appeared Age when diagnosed Did any events accompany onset of autism? Did child receive all standard vaccinations? Was there any react to the MMR or other vaccination? What conditions or symptoms does child suffer most from? What is your level of knowledge on nutrition intervention for ASDs? Very well read Have done some reading and have started dietary intervention Very new to all of this How can a nutrition consultant best support you? Therapies/Protocols (Indicate what you are you interested in, are using, or tried in past) DAN! Protocol GFCF OT/PT/ABA Patricia Kane Specific Carbohydrate Diet Sensory integration Chelation Yeast protocol Homeopathy Feingold Body Ecology Diet Energy work Other (415)
2 PRENATAL/INFANT Number of children in family and order (i.e. 2 nd of 3 children) Names/ages other children Describe the pregnancy Was child breast-fed? How long Did the child receive formula? What type (cow, soy)? What was the reaction to formula? Did child have thrush as a baby? Was the mother exposed to any chemicals or medications during pregnancy, or received any amalgam fillings or vaccinations (including Rh immune globulin or flu shot)? HEALTH HISTORY OF CHILD Describe the health history of the child from birth (i.e. ear infections, illnesses, viruses): _ How many times has the child received antibiotics and at what age? Please describe Does child have heavy metal or other toxicity? Is child currently taking any medication? Please list supplements child is taking: Have you tried cod liver oil and was there any improvement? (415)
3 DIET What is child s current diet? Do you (circle one) suspect or know that your child is: Gluten sensitive Casein sensitive Explain Has child tried a strict gluten/casein-free diet? If yes, for how long? Did you notice a reduction in symptoms? Does your child have any other food sensitivities? Eggs Corn Sugar Soy Chocolate Peanuts Citrus Other Does child have any significant food cravings, or demand or sneak food? Phenols/Salicylates Are you familiar with phenols, salicylates, and faulty sulfation? Do you suspect your child has a phenol sensitivity? Is there a reaction - [hyperactivity, red cheeks, aggression, etc.] to the following phenols/salicylates? (circle): Apples/juice Grapes/raisins Peppers (bell or chili) Almonds Tomatoes Berries/Raspberries Honey Any fruit Curry powder Spices Cola drinks Cider/vinegar Nitrates/nitrites Preservatives Sulfites Artificial colors/flavors Aspirin Pepto Bismol Perfumes Tylenol (acetaminophen) Does your child only eat foods of certain textures? Are there any textures your child will not eat? Does he/she tend to focus on one taste (sweet, bitter, sour, salty, spicy) Are there any tastes he/she will not eat? DIGESTION AND ELIMINATION Does child have frequent gas or bloating? Does gas have an odor? (415)
4 Does child appear to have abdominal pain? Does child have diarrhea or soft, unformed stool? Does child have constipation? Does child have heartburn or acid reflux? Does child take antacids or acid blockers? _ Does child get nauseous or vomit? Does child have yeast or bacterial overgrowth? Describe any other digestive issues? How frequently does child have a bowel movement? Once/day Every other day Twice/day Every 2-3 days More than twice/day Greater than 3 days What is consistency of stool? Formed like a brown banana Unformed, soft, or ribbon-like Small balls formed into banana, or rabbit-pellets Very large diameter FAMILY HISTORY Do mother or father have any food sensitivities? Does mother have any chemical sensitivities or allergies? Common Familial Disorders Please indicate any family history of the following and list family member affected, mark paternal or maternal with a p or m. For example: p-grandmother, m-aunt ADD/Hyperactivity Depression, postpartum, SAD, bipolar Asperger s or other ASDs High estrogen/low progesterone Alcohol/chemical dependency Heavy or irregular menses Epilepsy Threatened or actual miscarriage Rheumatoid arthritis Diabetes/hypoglycemia Food/environmental allergies Impaired immune function Milk intolerance Recurring yeast (vaginal, foot, etc.) Impaired fat digestion/loose stools Recurring sinus infections Asthma Dermatitis/rashes IBD/Crohn s disease Multiple chemical sensitivity Cancers of GI Tract Fibromyalgia or chronic fatigue Schizophrenia Active Epstein-Bar virus Alzheimer Hypothyroid Other psychiatric condition Parkinson s diseases (415)
5 Autism Evaluation Please rate the following behaviors or symptoms on a scale of 1 to 7 (1 mild; and 7 very true or severe) as they appear today. This will help determine how the child progresses. Communication (0) Not apply (1)Mild (7)Very true Cannot communicate verbally Receptive language is difficult Reverses pronouns such as you and I Has echolalia repeats others words Can not rationalize with child Behavioral/emotional symptoms Does not respond to requests by familiar people Has picky eating habits Throws frequent tantrums Behaves aggressively, physically attacking others Injures self with behavior (head-banging) Frequent crying Depression Irritability Panics easily or resists change Behavior challenges 2-3 hours after meals Hyperactivity Spacey/Inattentive Low impulse control Physical Symptoms Is physically inactive, or passive Fatigue/low muscle tone Hypersensitive (sound, touch, etc) Insensitive to pain Headache Tics/Tourette s Asthma Bedwetting/daytime wetting Red checks or streaks on face Dark circles under eyes Hives/rashes Congestion/runny nose/allergy symptoms Resistance to go to bed Difficulty falling asleep Night waking/nightmares/erratic sleep Seizure activity Please remember to include copies of any lab tests that have been run No tests have been run yet (415)
6 1. Please write out child s daily diet. (If diet varies, fill out a diet record for at least two days). Include portion size and any supplements or medications. Include time of day. 2. Additionally, record any symptoms experienced during or after eating, such as drowsy, irritable, energized. Include bowel movements. Time Food/Supplements Mood/Energy/Symptoms Example 9:00 1 cup of Cheerios with 3/4 c of cow milk 10:00 Hyperactive 1 Flintstone s multi-vit/min, 500 mg vit C Constipation Breakfast Food/Mood Record Snack Lunch Snack Dinner Night-time Eating (415)
7 Nutrition Consultant Service Agreement I,, am consulting with Julie Matthews, Certified Nutrition Consultant, to gain information on health and wellness for my child,. I understand that Julie Matthews is not a physician and that she does not dispense medical advice nor prescribe treatment. Rather, she provides information to enhance my knowledge of how nutritious foods, herbs, supplements, and lifestyle affect health. Julie Matthews training includes a two-year certification program in nutrition education and consultation from the Institute for Educational Therapy. The methods of evaluation employed on my behalf, which may include diet, supplementation, and assessment analysis, are not intended to diagnose disease. I specifically authorize the use of these assessments, so that we can develop an appropriate dietary and health-supporting program for me, and to monitor my progress towards achieving my health goals. These services are not a substitute for medical care, and do not claim to diagnose, treat, or alleviate disease. Nutrition consultation services are not licensed by the state of California, they are alternative or complementary to the healing arts services licensed by the state. For medical diagnosis and treatment of disease, I would need to consult with a medical physician, or other licensed healing arts practitioner. I certify that I am here solely on my own behalf. I am not representing any other person, company, association, and/or on the behalf of any governmental agency. My child currently is is not under the care of a physician for a health problem or medical condition. If so, please describe. I give Julie Matthews permission to contact my child s physician,, at the following phone number on my behalf. The purpose of this contact is to attain additional information from the doctor on his/her diagnosis or recommended treatment, in order that Ms. Matthews may work in concert with the physician to provide me with appropriate and complementary information. I agree to hold Julie Matthews harmless for claims or damages in connection with our work together. This is a contract between Julie Matthews and myself and it is also a release of her liability. I understand Julie Matthews has a 24-hour cancellation policy. I am aware that I will be charged her standard consulting rates for the missed appointment if proper notice has not been given. Mother s Signature: Name: Date: Father s Signature: Name: Date: (Please have mother and father sign form.) (415)
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