Parent Confidential Questionnaire

[vc_row][vc_column][vc_column_text]Autism Management Limited – #2 in a series of informative papers
Dr Edward Danczak
(Some pre-preparation of the information needed to complete this questionnaire will reduce your online time – Dr Edward Danczak)

QUESTIONNAIRE: Autistic Spectrum disorders

MEDICAL HISTORY

What is the diagnosed condition of this child?

Please list if more than one

Child’s height: Child’s weight:

Has the child suffered from:
Sinus problems If yes when
Ear problems If yes when

Has the child had ear operations?
Grommets inserted?
Repair of ear drum?
Mastoid repair ?

Has the child had Sore throats? When was this?
Has the child been medically treated for this?

Has the child shown particular interest in certain foods?

Does the child refuse to eat foods?

Does the child vomit after foods?

Is the child hot at night?

Are the bedclothes thrown off?

Is the child wakeful, with a poor sleep pattern?

Has the child shown particular interest in certain foods?

Does the child vomit after foods?

Does the child suffer from Constipation?

Is the child still dependent on nappies?

Does the child refuse to eat foods?

Does the child have diarrhoea?

Is the child trained to use the toilet?

Does the child have a history of stomach cramps as a baby?

( Sometimes known as Baby Colic) How long did this last?

Has the child been given an exclusion diet?

How long was he on it for?

Who instructed the exclusion diet?

Has the child been tested chemically for Sulphite in the urine?

When was this?

What was the sulphite test result?

Has the child been tested chemically for food opioids by urine test?

When was this?

Result?

Has the child been given anti candida medication?

How long did this last?

Who gave the anti candida medication, and on what basis?

Has the child received mineral supplementation?

What type of mineral supplementation was given?

How long did this last?

What was the effect of the mineral supplementation?

Has the child been given multi-vitamin preparations?

What type of multi-vitamin was given?

How long did this last?

Has the child been treated with homeopathic preparations?

What type of homeopathic preparation was given?

How long did this last?

Has the child been given an anti-opioid such as Naltrexone?

How long did this last?

Who gave it?

Has the child been given RITALIN?

Who gave it?

How long did this last?

Is the child currently taking any medication?

Please list each medication, and for how long, in weeks, in brackets

Does the child have any of the following:

Eczema?

Psoriasis?

Rash reactions to foods?

Asthma?

Arthritis?

Does the child have any conditions affecting the:

Cardiovascular system?

Respiratory system?

Kidney and bladder?

Please list any conditions affecting the Kidney and Bladder:

Please list any major infections e.g. Malaria:

Has the child suffered from epilepsy?

If so for how long?

What treatment has been given?

Does the family have a history of any of the following:

(Please include parents and Grandparents on both sides of the family)

Asthma

Eczema

Psoriasis

Dyslexia

Irritable bowel

Chronic fatigue syndrome (CFIDS)

Rheumatoid Arthritis

Osteoarthritis Arthritis of more than one joint

Lupus

Crohn’s disease

(Autoimmune diseases)

Liver disease

Skin disease

Joint disease

Diabetes

(Psychiatric Illnesses)

Depression

Anxiety

Schizophrenia

Manic Depression

Psychosis

Has the child had vaccine immunisations?

MMR?

Diptheria?

Polio?

Tetanus?

Whooping cough?

Please list any immunisation types for which there was a related reaction:

Has the child had any surgical operations?

Please list the dates and procedures:

Has the child been investigated by any of the following:

Psychologist?

Paediatrician?

Neurologist?

Please add any further medical history you feel is helpful:

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Copyright © 2000 [Autism Management Limited]. All rights reserved.
Revised: September 07, 2000 .
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