osteopathic healthcare of maine

Autism-Spectrum Health Questionnaire
(includes children without an official diagnosis)
Please bring this completed form with you to your initial visit with Dr. Keelyn Wu
at the Portland Osteopathic Children’s Clinic.

Child’s Name:___________________________ Today’s date_______________________ Child’s Age:______ Date of Birth:__________Referred by:_________________________ Parent(s)Name(s):_________________________________________________________Pediatri cian/PCP:_____________________________List other providers (PT, OT, speech therapist, homeopaths, etc.) with phone #:_______________________________________ ______________________________________________________________________________ __________________________________________________________________ Sex: Male: ____ Female: ____ Weight: _____ Siblings with ASD/ADHD?___yes___no Age of Autistic Spectrum Disorder (ASD) diagnosis:_____Official Diagnosis_____________ Is child’s ASD classified as: Mild ___ 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, ie. poor eye contact, aggressive behavior, etc.):__________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________ What developmental issues does child suffer with currently if different from above?_______ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________ Please describe any other event, action, etc. that you think may have some bearing or relationship to your child’s condition. Please be as detailed as possible._________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________ Other Health Issues:
Does your child suffer from other health problems? ___Food Allergies ___Seasonal / Environmental Allergies____Asthma ___Eczema___ Kidney Problems ___Lung Disease ___ Diabetes ___Thyroid Disease ___Heart Disease___ Seizures ___ Repeated Infections ___OCD Other, please explain____________________________ ________________________________________________________________________ Did your child’s condition change following an illness, infection and/or seizure disorder (such as ___No ___Yes, please explain________________________________________________ Digestive Health:
Did your child breast feed?___Yes___No How long?_________ If formula fed, what kind? _________________________Any adverse reactions?___Yes___No Did your child have colic as an infant?___Yes___No Does child have periodic loose stools/diarrhea?___Yes __No Constipation?___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 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 ___ 1-5 Main reason for antibiotic use: ___Ear Infections ___Bronchitis ___Pneumonia ___Sinusitus ____Intestinal Infection ____Other (please explain)______________________________ Was your child ever treated for a yeast infection following antibiotic use?___Yes____No Did your child ever receive probiotics after antibiotics?____Yes____No Medication Allergies: ___Yes____No/Unknown (if answer is “yes”, please list)_______
_______________________________________________________________________ Home Environment:
How old is your current home?____ Has your child lived in a home that had lead-based paint? Is your flooring carpet? ___ hardwood or tile?____ Has there ever been any exposure in the home to molds? ___Yes ___No Has your child used or currently sleeps in fire retardant clothing or bedding? ___Yes ___No Is child exposed to outside pesticides, fungicides, etc.? ___Yes ___No Does your child consistently swim in a chlorinated swimming pool?___Yes___No Please list pets:__________________________________________________________ Social History
Is your child interested in other children?___Yes___No Any interests or hobbies?____________________Recent changes, losses, births, deaths, divorce, remarriage or moves?_______________________________________________ Mother’s Pregnancy and Labor:
Did Mom have any complications during pregnancy? ___High Blood Pressure___ Seizures ___ Diabetes___Infections with 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 If yes, which ones? ___________________________________________________________________ Did Mom receive any vaccinations after pregnancy while breastfeeding? ___Yes ___No Was your child delivered vaginally?___ or C-section?___ Forceps and/or suction devices used?___Yes___No Was there any concern for birth trauma?___Yes___No Mother’s Medical History:
___Low Thyroid ___ Thyroid Cancer ___ Parathyroid problems ___ Nightblindness (difficulty ___Autoimmune Disorders (Lupus, Connective Tissue, Rheumatoid Arthritis, Autoimmune Thyroid, Crohn’s, Ulcerative Colitis, etc.) Mercury Fillings in Mouth? ___Yes___No Dental work that contains Nickel? ___Yes___No ____Other, please explain__________________________________________________ Did Mom have any dental work done during pregnancy? ___Yes ___No Did mom have mercury fillings removed while breastfeeding child? ___Yes ___No Use of birth control pills?____Yes_____No How long?_________ Does mom have any digestive conditions? (GERD, IBS, chronic constipation, etc.)?____Yes ____No If “yes”, what condition(s)?_________________________________________ How many courses of antibiotics has mom received?___0____1-5____5-10____10 or more Family History:
Is there a family history of Developmental Disorders, i.e. Autism, PDD?___Yes___No Please explain:___________________________________________________________ Is there a family history of other Neurological Disorders, i.e. Multiple Sclerosis, etc.? ___Yes___No Please Explain:___________________________________________ Is there a family history of Asthma, Allergies, Autoimmune Disorders (Lupus, Rheumatoid Arthritis, etc.)?___Yes___No Please Explain:___________________________________ 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?___Yes____No Is there a family history of Seizures, Vaccine Reactions?___Yes___No Is there a family history of Celiac Disease, or Gluten Intolerance?___Yes___No Any other relevant family history?____________________________________________ 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 changed after a particular vaccination? ____Yes _____No. If ___________________________________________________________________ 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 If “yes” please explain:______________________________________________________ Did your child suffer any vaccine reactions? ___Yes___No Please check if answer is “yes”: Fever __Inconsolable screaming__ Excessive lethargy___Rashes ___Vomiting ___ Seizures ___Other, Please explain: ___________________________________________ Medication Usage:
Has child taken steroid medication? ___Yes ___No. If Yes, which kind? ___inhaled ___oral Has child taken medication for yeast/candida infection? ___No ___Yes, please list_______ _______________________________________________________________________ Is child currently taking medication or supplements for yeast? ___Yes ___No If “yes”, 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 Oil, Flax, etc:_____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What does your child like to eat?______________________________________________ ________________________________________________________________________ Is child on a Gluten Free Diet? ___Yes ___No Is child on a Casein Free Diet? ___Yes ___No Has child benefited by being on a GF/CF diet?___Yes___No Is child on a Specific Carbohydrate Diet (SCD)?___Yes___No Is child on a Low Oxalate Diet?___Yes___No Other diet (please explain)___________________________________________________ DAN! Therapies:
Has your child seen a DAN! physician?__Yes___No If so, who?______________________ What biomedical testing and treatments were performed? Please explain:_______________ ______________________________________________________________________________ __________________________________________________________________ Does child currently have Mercury/Amalgam/Silver Fillings? ___Yes ___No Has child received Mercury Chelation w/DMSA? ___Yes ___No DMPS? ___Yes ___No Any benefits from chelation therapy?__Yes___No Have you attended any DAN! conferences or other educational seminars?___Yes___No Are you a member of a biomedical autism support group? ___Yes ___No What autism-related books have you read?_______________________________________ What biomedical therapies are you interested in? __________________________________ Other Important Information:
If pertinent, please tell us more about the medical history of your child in relation to their autism diagnosis on the back side of this page.
Physician Only:
Patient’s history reviewed (date and initial): ___________________________

Source: http://www.portlandocc.org/ASD_Questionnaire_POCC.pdf

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