Parents' (or guardians') full names; ages; occupation. Are there any parental issues (such as divorse, separation, child custody, etc.) which may impact consistency in the child's diet?
Child's full name
Age; Date of birth; Gender
Address
Mobile phone number
Email address
Child's developmental (ASD) diagnosis; Level: 1,2,3? At what age; Diagnosing physician's name and specialty
At what age did you first notice or suspect any concerns regarding your child's behaviors or development?
What behaviors did you first notice that might be unusual?
Would you say this was a "sudden" onset or a more gradual development?
Do you feel that your child's pediatrician (or other practitioner) would be supportive of the use of diet modification and supplements to treat your child's autism?
Do you have other children? Do you have any concerns regarding their development?
Is there any family history of developmental delay or behavioral issues? Please explain.
How would you describe your child's overall health?
What is your child's height and weight? Do you have any concerns about their growth pattern.
Does your child have any issues with muscle tone? Oral-motor, fine or gross motor skills?
Was your child born at term or premature? If premature, at how many weeks? Natural birth or C-Section?
Was your child breast-fed? For how long? Bottle (formula) feeding?
Has your child been in the hospital other than at birth? For what reason(s) and for how long?
At what age did you start introducing baby foods? Solid foods or table foods? Were there any problems?
Did your child receive the "standard" vaccine regimen? Were there any notable reactions following any injections?
Is your child receiving (or had been) any "traditional" therapies, including ABA, speech, feeding, sensory integration or physical therapy? Please describe fully.
How knowledgeable would you say you are with dietary and "biomedical" intervention for autism? You may mention any resources, including organizations and websites, you have used or explored. Please include support groups or other families with ASD kids.
Have you tried any dietary or biomedical intervention, including use of supplements or any other therapies? When? Have these been helpful for your child?
Has your child suffered from recurrent or severe ear infections as a toddler or infant? Approximately how many times in the past year? And how was this treated?
Approximately how many times has your child had a fever over 101 degrees? How was this usually treated?
What do you feel are your child's most significant problems? What are you most concerned about? Please feel free to mention any issues you feel may be relevant.
Please describe any other developmental, physical, medical or psychological issues. Please be as complete as possible.
Is your child potty trained? Does your child have any problems with constipation or diarrhea? Please describe the usual color, odor and consistency of their stool.
Are there any unusual behaviors associated with toileting?
Please describe any other GI problems, such as bloating, encopresis, foul odor, etc.
Would you consider your child to be a picky eater? Or a "problem feeder?" Please describe his eating habits and your feelings about his diet and eating habits.
Please list their five favorite foods (eaten nearly every day).
Please list a few other foods your child is usually willing to eat.
What are your child's reactions to being encouraged to eat a new food?
What are some foods they will "never" even touch?
What are your feeling toward "organic," non-GMO foods or "natural" products?
Which grocery stores do you usually shop at?
Do you, or have you in the past, lived in a rural area?
Do you use any pesticides or herbicides, including Roundup?
How old is your home? Have you ever experienced flooding or water damage in your home (or apartment)?
Please list some of your usual household cleaning products.
Please give thought to this question: What are your feelings and expectations in entering into our functional nutrition approach toward treatment of your child?
Is there anything you would like to add?
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