Autistic-Spectrum Disorder

Health History Information:
Child's Name   Child's Age   Date of Birth   Male Female
Age of Autistic Spectrum Disorder (ASD) Diagnosis?
Is child classified as Mildly ASD Moderate Severe
Symptoms became apparent at what age?
What signs and symptoms first became noticeable that alarmed you as a parent? (please list as many initial developmental problems as possible, i.e. poor eye contact, aggressive behavior, etc,):

What developmental issues does child suffer with currently if different from above?


Other Health Issues:
Does your child suffer with other health problems? Allergies Asthma Constipation Diarrhea Eczema Kidney Problems Lung Disease Thyroid Disease Heart Disease Seizures Repeated Infections
Other, please explain

Digestive Health:
Does your child have periodic loose stools/diarrhea? Yes No
Offensive Gas? Yes No Undigested Food Stuff in Stools Yes No
Is you child potty trained? Yes No
Does your child suffer with reflux/heartburn? Yes No
Is your child currently taking an acid-blocking medication such as Tagamet, Pepcid, etc? Yes No
Did occurrence of digestive problems occur following a particular vaccine? Yes No
Does your child produce formed stools? Yes No
Have they ever produced formed stools? Yes No

Antibiotic History:
How many courses of antibiotics has your child received in lifetime (approx)? 0-5 5-10 10-15 15-20 20+
Main reason for antibiotic use? Ear Infections Bronchitis Pneumonia Sinus Infection Intestinal Infection
Other (please explain)

Home Environment:
How old is your current home? Has your child lived in a home that lead-based paint Yes No
Is your flooring carpet hardwood Tile
Do you have carpeting in he bathrooms? Yes No
Has there ever been exposure in the home to molds? Yes No
Has your child used or sleep in fire retardant clothing or bedding? Yes No
Do you use commercial cleaners in the home? Yes No
Is child exposed to outside pesticides, fungicides, etc? Yes No
Please list pets and/ or farm animals your child is exposed to

Mother's Pregnancy and Labor:
Did Mom have any complications during pregnancy, i.e. High Blood Pressure Seizures Infections tat antibiotic treatment Viral Infections (Flu, Mono)
Does Mom know her Rh status? (+ or -) Blood type
Did Mom receive Rhogam during pregnancy? Yes No
Did Mom receive any vaccinations during pregnancy? Yes No   Which ones?
Did Mom receive any vaccinations after pregnancy while breastfeeding? Yes No
Was your child delivered vaginal or C-section
Forceps and/or suction devices used?
Was there any concern for birth trauma?

Mother's Medical History:
Low Thyroid Thyroid Cancer Parathyroid problems Night blindness (difficulty seeing at night) Autoimmune Disorders (Lupus, Connective Tissue, Rheumatoid Arthritis, Autoimmune Thyroid) Mercury Fillings in Mouth
Dental work that contains Nickel
Other, please explain
Did Mom have any dental work done during pregnancy? Yes No

Family History:
Is there a family history of Developmental Disorders, i.e. Autism, PDD? Please explain:

Is there a family history of other Neurological Disorders, i.e. Multiple Sclerosis, etc.

Is there a family history of Asthma, Allergies, Autoimmune Disorders (Lupus, Rheumatoid Arthritis, etc.)?

Is there a family history of Clotting or Blood Disorders, Strokes, Hemophilia, Platelet Disorders?

Is there a family history of Psychiatric Disorders, i.e. Depression, Schizophrenia, etc?

Is there a family history of Genetic disorders?

Is there a family history of Seizures, Vaccine Reactions?

Is there a family history of Celiac Disease, or Gluten Intolerance?


Vaccination Status:
Has child received all the recommended vaccinations for their age? Yes No
Has your child received: DTP DtaP MMR Hib Hep B OPV
IPV Pneumonia Chicken Pox Flu
Others (please list)
Do you feel your child's behavior change after a particular vaccination? Yes No
If yes, please indicate which vaccine(s)
How long after the above vaccine(s) did child become symptomatic? (ex. Minutes, days, etc.)
Did your child receive any vaccinations when they were sick? Yes No  
Please explain
Did your child suffer any vaccine reactions? Fever Inconsolable screaming Excessive lethargy Rashes Vomiting Seizures Other

Medication Usage:
Has child taken steroid medication? Yes No.   If yes, which kind? Inhaled Oral
Has child taken medication for yeast/candida infection? Yes No   Please list
Is child currently taking medication for yeast? Yes No
Are they taking supplements for yeast? Yes No   Please list
Please list other medication child is currently taking


Supplements:
Please list all supplements child is currently taking, including nutritional oils, i.e. Cod Liver, Flax, etc:


Diet Is child on a Gluten Free Diet? Yes No
Is child on Casein Free Diet? Yes No
Has child benefited by being on a GF/CF diet?

Dan! Therapies:
Has child received Secretin Yes No   If yes, have they benefited
Is child receiving Cod Liver Oil Yes No   Any benefits?
Is your child receiving Botanical Treatment? Yes No   Any benefits?
Is child currently receiving IVIG therapy? Yes No
Does child currently have Mercury/Amalgam/Silver Filling? Yes No
Has child received Mercury Chelation w/DMSA? Yes No   Any Benefits?
Has child received Chelation Therapy for other Heavy Metals besides Mercury?
Has your child taken antifungals in the past, i.e. Nystatin, Diflucan? Yes No
Is child taking Transfer Factor? Yes No   Colostrum? Yes No
Other DAN! Therapies

Other Important Information: If pertinent, please take the time to tell us more about the medical history of your child in relation their autism diagnosis.