Parental Questionnaire (CONFIDENTIAL)

E-mail_____________________________Date__________________________Phone #_____________

CHILD:Name:_______________________________Age:_________Birth Date:_________________________
Current Weight (kg)__________________________________________________________________________
Present height________Weight_______Size in relation to same age peers_________________________
Address:_____________________________________________________________________________________
_____________________________________________________________________________________________
GP (including address):_______________________________________________________________________
Father’s Name:______________________________________________________________________________
Mother’s Name:_____________________________________________________________________________
Siblings, Gender and Ages:___________________________________________________________________
List those living in primary home:______________________________________________________________
List those living in secondary home:___________________________________________________________

FATHER:
Medical history:______________________________________________________________________________

Immune illnesses (e.g.): Allergy, Asthma, urticaria, auto-immune, psoriasis:

_____________________________________________________________________________________________
Illnesses in paternal family:____________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Any history of autism, ADHD, Bipolar, Schizophrenia, depression, addictions, Alzheimer disease,
Multiple
Sclerosis?_____________________________________________________________________________
_____________________________________________________________________________________________

MOTHER
General Health:______________________________________________________________________________
Medical history:______________________________________________________________________________

Immune illnesses (e.g.): Allergy, Asthma, urticaria, auto-immune, psoriasis:

_____________________________________________________________________________________________
Illnesses in maternal family:___________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Any history of autism, ADHD, Bipolar, Schizophrenia, depression, addictions, Alzheimer disease,
MultipleSclerosis?____________________________________________________________________________
_____________________________________________________________________________________________
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Patient’s questionnaire ATT clinic- December 07

How many amalgam fillings?_________________________________________________________________
When placed?______________________________________________________________________________

Any medical procedures during pregnancy?__________________________________________________

Any unusual event during pregnancy?________________________________________________________

____________________________________________Rh neg?_________________________________________

Child’s Birth place:__________________________________Type of delivery:_________________________

Difficulty of Labor:____________________________________________________________________________
Condition at birth:____________________________________________________________________________
APGAR:______Wt:_____Mother’s age at delivery:_______________________________________________

Other event during delivery?_________________________________________________________________

Any amalgam fillings placed in mother during pregnancy or breast feeding?___________________

CHILD

Breast Fed/How long:________________________________________________________________________

Allergies____________________________________Injuries___________________________________________
_____________________________________________________________________________________________
Infections_________________________________________Fevers_____________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Treatment with antibiotics____________________________Reactions_______________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Surgeries, tubes in ears_______________________________________________________________________
Seizures: Age of onset, type, accompanied by fever, timing re illnesses, injuries, vaccinations:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Vaccination history and describe any adverse reactions or changes in behavior after receiving
(if need be detail on separate sheet, you can include full medical vaccination record):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Patient’s questionnaire ATT clinic- December 07

_____________________________________________________________________________________________
If abnormal reaction to vaccination, have the events been reported and noted by your child’s
doctor?

_____________________________________________________________________________________________

Has your child had a disorder since birth, or later onset? Please describe First sign of concern
and outline development of condition?
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Closest personal bond (usually):______________________________________________________________

When Never
Age at onset of delays/problems
Age at onset of regression
Sitting up
Crawling
Pulled to stand
Walked alone
Potty trained
Dry at night
First words
Spoke clearly
Lost language
Lost eye contact

Amalgam fillings; how many and what age?__________________________________________________

Patient’s questionnaire ATT clinic- December 07

PAST AND CURRENT MEDICAL HISTORY
General Skin Cont'd Immune
Poor temperature control Oily skin Allergic Rhinitis
Night sweats Pale skin Asthme
Stiffen body/ different posture Psoriasis Bronchitis
Unusual flexibility Rashes Chemical sensitivities
Fatigue Warts Chest congestion
Fast heart rate Chronic cough
High pain tolerance Eyes Food allergies
Joint pain Dark circles under eyes Frequent cold infections
Headache Dilated pupils Hay fever
Upper body pain Divergent gaze Lymph nodes enlarged
Ringing in the ears Poor eye contact Seasonal allergies
Seizure Visual stims
Tics Yeast
GI Athlete's foot
Skin Abdominal pain Feet cracking, peeling
Acne Bloating Nail fungus
Body odor Burping Red ring around anus
Blotchy skin Colic Ring worm
Cold Sores Constipation Thrush
Chicken skin Diarrhea Vaginitis
Burns easy Flatulence
Cradle cap Stools/ Bulky
Dandruff Stools/ Bloody
Dry skin Stools/ Float
Eczema Stools/ Light color
Flushing Stools/ Mucus
Gums blleed Stools/ Mushy
Hives Stools/ Strong odor
Itchy skin Stools/ Undigested food
Stools/ formed
Stools/ soft
Stools/ liquid

P: Past, C: Current

DIET

Eating Patterns: Infant_______________________Formula base (milk, soy, etc)_____________________

Toddler______________________________________________________________________________________
PICA? (eating/chewing non eatable things)___________________________________________________

Favorite foods___________________________Most disliked foods__________________________________

Patient’s questionnaire ATT clinic- December 07

List any special diets and reactions/results_____________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________

Child positioning themselves as to apply pressure on lower abdomen, with pieces of furniture
(Sofa, arm chairs) or on the floor.

Please provide details

Details of any dietary interventions

Patient’s questionnaire ATT clinic- December 07

CURRENT DIET
Type of food Helpings per Helpings per Helpings per Helpings per
week: 0 week: 1-3 week: 3-5 week: >5
Bread
Pasta
Rice
Potatoes
Green vegetable
Other
vegetables
Lettuce
Fruits
Meat
Chicken
Fish
Cheese
Sweets
Biscuits
Chocolate
Juice
Fizzy drinks
Crisps
Water
Milk
Rice milk
Soy Milk
Other drinks
Fast food

Type of diet

How would you rate your child diet?

Description Yes Moderately so No
Restricted
Self restricted
Picky eater
Broad diet
Organic food
GF/CF diet
GF/CF soy free/corn free
GF/CF soy free/corn free/ sugar free

LABORATORY TESTINGS:
Results of chromosomal studies: ______________________________________________________________
Fragile X (state if done or not and what is the result)____________________________________________
EEG:_____________________________________________MRI:_______________________________________

Patient’s questionnaire ATT clinic- December 07

List any laboratory studies undertaken and results (date and positive or negative if don’t know
actual values):
Organic acid_________________________________________________________________________
Stool analysis or other gastrointestinal studies___________________________________________
Urinary peptides______________________________________________________________________
Immune function tests_________________________________________________________________
Fatty acid analysis____________________________________________________________________
Heavy metals studies__________________________________________________________________
Amino acids, Vit. Zinc, other nutrients__________________________________________________
Hair analyses_________________________________________________________________________
Any others not listed__________________________________________________________________________
_____________________________________________________________________________________________
List any medications in past and currently taking, times and doses______________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
List any nutrients/vitamins currently taking, doses, any reactions (Use separate sheet if need be)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have a personal opinion as to why your child is developmentally delayed?______________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please give any other information that might be helpful in evaluating your child: please send a
current photo with siblings/family if possible.___________________________________________________

OTHER HEALTH ISSUES:

Sleeping patterns:____________________________________________________________________________
Nightmares:__________________________________________________________________________________
Place of Education:__________________________________________________________________________
Disruptive/anti-social behavior in public_______________________________________________________
Teacher comments/reactions:________________________________________________________________
_____________________________________________________________________________________________
Describe general personality:_________________________________________________________________
Mood swings:________________________________________________________________________________

Patient’s questionnaire ATT clinic- December 07

Hyper or hypoactive?________________________________________________________________________
Inconsolable crying spells:____________________________________________________________________
Friends: Make easily: __________________________________________Keep:_________________________
Relation to Adults:___________________________________________________________________________
Imagination pattern:_________________________Imaginary friends:_______________________________
Handedness:________________________________________________________________________________
Eye contact (rate as good, moderate issue, serious issue):_____________________________________
Affection (please state towards whom or what):_______________________________________________
Alertness:____________________________________________________________________________________
Favorite activities:___________________________________________________________________________
Repetitiousness______________________________________________________________________________
Relation to animals:__________________________________________________________________________
Fears of dark, water, strangers:________________________________________________________________
Favorite object(s):_________________________Reaction to change______________________________
_____________________________________________________________________________________________
Unusual fears/phobias/attachments:__________________________________________________________
_____________________________________________________________________________________________
Sense of humor:______________________Self-sufficiency:_________________________________________

Toilet Trained: Urinary Yes/No Bowel Movements: Yes/No

Self Directed Aggressive Behavior: Yes/No

Self Injury Behaviour: Yes/No Specify:__________________________________________

COMMUNICATION, SENSORY AND COGNITIVE SKILLS

Please describe the child’s skills in the following areas:

Playskills:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Self care skills:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Patient’s questionnaire ATT clinic- December 07

Understanding of language:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Use of language:

Uses Single Words: Yes/No How many: _____

Uses Sentences: Yes/No
Uses Successive Sentences: Yes/No
Overall speech is functional in context: Yes/No

Any additional comments

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Use/understanding of non verbal communication:

PECS Yes/No
Sign Language Yes/No
Any additional comments
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Level of interaction (e.g. with sibling/peers/familiar adults

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Sensory issues (e.g. intolerance of particular sounds, smells, visual stimulus)

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Patient’s questionnaire ATT clinic- December 07

Self stimulatory behaviours:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Aggressive or tantrum type behaviours (please clarify if this is appears as “out of the blue” of as
response of demand/ or change placed on the child)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Details of any school/nursery placement:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Details of input from other professionals (e.g. speech and language therapist):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________

What concerns you the most?

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________

What are your child’s favourite activities?

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

What do you do to reward your child?

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Patient’s questionnaire ATT clinic- December 07

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Any other comments
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Please enclose copies of any relevant information for example diagnosis, assessments or reports

Research Agreement:

I agree for the patient’s laboratory results and family history to be used anonymously for
research proposes.

Date: Signature:

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Patient’s questionnaire ATT clinic- December 07