Dr. Sidney M. Baker · Web viewQuestionnaire for Children with Autism & Related Developmental and/or Attention Problems (Adapted from ARI Questionnaire c/o Sidney M. Baker, M.D.)

Eileen C. Comia, M.D.35 Jolley Drive Suite 102

Bloomfield CT 06002Tel (860)242-2200Fax (860)242-2212

[email protected]

Questionnaire for Children with Autism & Related Developmental and/or Attention Problems(Adapted from ARI Questionnaire c/o Sidney M. Baker, M.D.)

Note: In this questionnaire “you” is used as if the child were answering questions, avoiding repetition of him/her.First Name: MI: Last Name:

Birthdate (mm/dd/yy):

/ /

Birth Order: Place of Birth (city, state, country):

Male Female Eye Color: Hair Color:

Blood Type: A B AB O Rh ( + ) ( - )

Allergy to medication: Hair Texture:

Height: Weight: SS#: / /

Address Email:

Street: City/State: Zip:

Home Telephone: ( ) Referred by:

Mother's Name: Occupation: Phone:

Father's Name: Occupation: Phone:

Person(s) filling out this questionnaire:

Relation to Patient:

Date:

ABTC Questionnaire 0118

This questionnaire is intended to give you a way of describing yourself as an individual. Many of the questions have to do with details that are not required to “make a diagnosis” but may be biochemical or immunologic clues that influence our thinking about treatment options. Whatever label has been given to you, keep in mind that it is just a label, not a cause. Symptoms and other findings described in this questionnaire are the body’s way of speaking to us about causes. Our job is to listen and learn. Thank you. Eileen C. Comia, M.D. Sidney M. Baker, M.D.

Symptom score sheet for monitoring progress: Record the main problems in the Symptom column. Choose the most difficult problems as well as symptoms that may indicate progress.# =rank, P= past, L= lab, (symptom scores go in the columns below dates)

Symptom (0= Absent, 3= mild, 6= Moderate, 9=severe 12= incapacitating.)

Date

0 Example: Poor expressive language 9123456789101112

Laboratory data:

Evaluation/Test Date Done? Abnormal? Not sure?

24 hour urine amino acids

Amino acid screen

Blood chemistry screen

Blood count

Blood test for fatty acids

Blood test for food allergies

CAT scan

Colonoscopy

DMSA loading study

EEG

Folic acid

Fragile X chromosome study

Hair elements

Immune profile

Intestinal permeability

Liver Detoxification profile

MRI

Organic acids quantitative – fungal/bacterial metabolites

Organic acids quantitative – metabolism


2

Evaluation/Test Date Done? Abnormal? Not sure?

Organic acids screen

PET scan

Pinworm prep

Plasma amino acids

Plasma or serum zinc

RBC elements

Serum Ferritin (iron stores)

Serum methylmalonic acid

Serum Vitamin A

Small bowel biopsy

Stool culture

Stool parasites

Thyroid Profile

Uric acid test (blood or urine)

Urinary Peptides

Urine elements

Urine Kryptopyrrole


3

Personal Descriptive InformationWith whom do you live? And what do they do? (Include children, parents, relatives, friends...please include ages ) {Example: Wendy, age 7, sister, George, Dad, age 40, Lawyer]

Who are the main people who care for you?

Please describe your strengths and/or unusual skills:

What pets live with you - indoors or outdoors only?

When and where have you lived or traveled outside of the United States?

Major life changes recent or soon for you or your family?

Have you experienced any major losses in life?

What is your religion and how important is religion/spirituality in you and your family’s life?

Do you have a favorite toy or object?_______________________________________________________________________________________

Is there something else about you that I should know?


4

Past and present professionals:

Primary Care:

Primary Care

Specialist:

Specialist:

Therapist:

Other

Homeopathic:

Chiropractor:

Who made the initial diagnosis of autism/other disorder? When?


5

Past EvaluationsPlease indicate if you have had any of the following evaluations, treatments, or consultations by placing a check mark in the appropriate columns. Please attach any copies of reports or provide the addresses where the evaluations took place. Add comments (to back or attach sheet if needed).Check if Yes

Check if Abnormal Date Evaluation/Test

______________ Psychological Evaluations

______________ Wechsler Preschool & Primary Scale of Intelligence

______________ Speech and Language Evaluations

______________ Genetic Evaluation

______________ Neurological Evaluations

______________ Gastroenterology Evaluations

______________ Celiac/Gluten testing

______________ Allergy Evaluation

______________ Nutritional Evaluation

______________ Auditory Evaluation

______________ Vision Evaluation

______________ Osteopathic

______________ Acupuncture

______________ Physical Therapy

______________ Occupational Therapy

______________ Sensory Integration Therapy

______________ Language Classes

______________ Sign Language

______________ Homeopathic

______________ Naturopathic

______________ Craniosacral

______________ Chiropractic

Hospitalizations

Age Reason for hospitalization Discharge summary attached?


6

Operations InjuriesPlease indicate approximate age when you had an operation for:

AGEPlease describe any injuries

AGE

Appendix Head injuryCircumcision Broken boneHernia Broken boneTonsils Eye injuryAdenoids Neck injuryP.E. Tubes in Ears Abdominal injuryOther surgery Other injury

Please use this space for comments or narrative. You may wish to highlight those consultations, tests or treatments you found most, or least, helpful.


______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Immunization Please give approximate date if you don’t have a specific one.

Did you have any of the following reactions:“Bowel” means any bowl symptom such as diarrhea, “Swelling” means swelling at the site of the injection.

Diphtheria-Pertussis-Tetanus Date Bowel Swellin

gCryin

gSeizur

eIrritabl

eFever

Other

DPT 1DPT 2DPT 3DPT 4DPT 5Adult Diphtheria-TetanusPediatric Diphtheria- Tetanus

H Influenza type B Date Bowel Swelling

Crying

Seizure

Irritable

Fever

Other

Hib 1Hib 2Hib 3Hib 4

Oral Polio Vaccine Date Bowel Swelling

Crying

Seizure

Irritable

Fever

Other

OPV 1OPV 2OPV 3OPV 4OPV 5

Polio Vaccine Injection Date Bowel Swelling

Crying

Seizure

Irritable

Fever

Other

Polio Vaccine Injection 1Polio Vaccine Injection 2Polio Vaccine Injection 3Polio Vaccine Injection 4Polio Vaccine Injection 5

Measles-Mumps-Rubella Date Bowel Swelling

Crying

Seizure

Irritable

Fever

Other

MMR 1 xxxMMR 2

Hepatitis-b Vaccine Date Bowel Swelling

Crying

Seizure

Irritable

Fever

Other

HBV 1HBV 2HBV 3HBV 4

Miscellaneous Date Bowel Swelling

Crying

Seizure

Irritable

Fever

Other

Varivax (Chicken Pox)Tine TestOther:


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Mother’s Past Pregnancies: number of:Pregnancies_____ Live births_____ Miscarriages_____Mother’s Pregnancy: Place a check mark if any of the following occurred during your mother's pregnancy:

Did your mother: (Please describe if applicable)Difficulty getting pregnant (more than 6 months)Infertility drugs used Specify:In vitro fertilizationDrink alcoholDrink coffeeSmoke tobaccoTake ProgesteroneTake prenatal vitaminsTake antibioticsTake other drugs Specify:Excessive vomiting, nausea (more than 3 weeks)Have a viral infectionHave a yeast infectionHave amalgam fillings put in teethHave amalgam fillings removed from teethHave how many fillings in her teeth during? Number of fillings in your mom’s teeth when

pregnant?_________Have bleeding (which months?)Have birth problemsGroup B strep infectionHave C-section because ofUse induction for labor (such as Pitocin)Have anesthesia -what was used?Use oxygen during laborHave an x-rayHave Rhogam, if so how many shots How many when pregnant?_____Gestational DiabetesHigh blood pressure (pre-eclampsia)High blood pressure/toxemiaHave chemical exposureFather have chemical exposureMove to a newly built houseHouse painted indoorsHouse painted outdoorsHouse exterminated for insectsPregnancy:Total weight gain during pregnancy_________lb Doral weight loss during pregnancy_________lbPlease describe diet during pregnancy_____________________________________________________________________________________________________________________

Please describe labor_____________________________________________________________________________________________________________________


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PerinatalPlace a check mark if applicable:Very active before birth Yes NoHospital/Birthing Center Yes NoNeeded Newborn Special Care Yes NoAppeared healthy Yes NoEasily consoled during first month? Yes NoAntibiotics first month Yes NoExperienced no complications first month of life Yes No

Birth Weight and ApgarWeight at birth (lbs): Apgar score at 1minute: Apgar score at 5 mins:

Early Childhood Illnesses

Number of earaches in the first two years:

Number of other infections in the first two years:

Number of times you had antibiotics in the first two years of life:

Number of courses of prophylactic antibiotics in first 2 years of life:

First antibiotic at ____ months.

First illness at ____ months.

Description of Developmental ProblemsAt what age did developmental problems appear to begin? 0-1months

2-6 months 6-15 months 16-24 months After 24 monthsIs this impression shared among parents and others caring for the child?:__________________________________________________________________________________…Or does this impression as to the timing of onset differ among parents and others caring for the child?__________________________________________________________________________________Is the impression as to the timing of onset weak?__________________________________________________________________________________… or is the impression strong:__________________________________________________________________________________Developmental HistoryPlease indicate the approximate age in months for the following milestones: (example: walking 14 months):

NeverSitting up ___ monthsCrawl ___ monthsPulled to stand ___ monthsPotty trained ___ monthsWalked alone ___ monthsDry at night ___ monthsFirst words ("mama, dada" etc.) ___ monthsSpoke clearly ___ monthsLost language ___,monthsLost eye contact ___ months


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Medications and Supplements Past and Present:

Medication or Supplement(please mark the response by checking in the appropriate columns)

Taking now?

VE

RY

GO

OD

GO

OD

NO

RE

SP

ON

SE

BA

D

VE

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N’T K

NO

W

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TIVE

, TH

EN

GO

OD

Comments.

aast SUBSTANCES AFFECTING:CN CENTRAL NERVOUS SYSTEMcnap Clozaril (clozapine) CNAP Haldol CNAP Prolixin CNAP Risperdal CNAP Seroquel CNAP Stelazine CNAP Thorazine cnap Zyprexa CNO Antihistamine CNO Clonidine CNO Cogentin CNO Deanol (deaner, DMAE) CNO Dextromethorphan CNO Lithium CNO Naltrexone CNO St John’s wort CNs Anafranil CNs Depakene for behavior CNs Depakene for seizures CNs Depakote for behavior CNs Depakote for seizures CNs Dilantin CNs Felbatol CNs Gabitril CNs Keppra CNs Klonopin CNs Lamictal CNs Luvox CNs Mysoline CNs Neurontin CNs Paxil CNs Phenobarbital CNs Tegretol CNs Topamax CNs Trileptal CNs Valium CNs Zarontin CNs Zonegran CNss Adderall CNss Prozac CNss Zoloft CNst Amphetamine CNst Cylert CNst Dexedrine, Dextroamphetamine CNst Fenfluramine CNst Focalin CNst Ritalin


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Taking now?

VE

RY

GO

OD

GO

OD

NO

RE

SP

ON

SE

BA

D

VE

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D

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N’T K

NO

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TIVE

, TH

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GO

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Comments.

CNtr Buspar CNtr Chloral hydrate CNtr Valium CNtri Desipramine CNtri Mellaril CNtri Tofranil CNtrt Klonapin df Antibiotics df Bactrim (Septra) Df Biochoice df Bismuth df Colostrum df Diflucan df DIGESTIVE FLORA df Humatin df Lamisil Had die off?df Nizoral Had die off?df Nystatin Had die off?df Probiotics (acidphilus, etc) Had die off?df Saccharomyces boulardii Had die off?df Sporonax Had die off?df Transfer factor (oral) Had die off?df Yodoxin Dg Bethanecol Dg DIGESTION Dg Digestive enzymes Dg Pepsid Dg Peptidase Enzymes Dg Probiotics Dtx DETOXIFICATION Dtx DMPS Dtx DMSA (succimer, Chemet) Dtx Reduced glutathione (transderm) Dtx Reduced glutathione IV Dtx Reduced glutathione oral M B6 & Magnesium M Brain child supplements M Folic Acid M Melatonin M Multivitamin high potency M Multivitamin regular potency m Nutrition and Metabolism M Super Nu Thera M Ultra Clear Sustain M Vitamin B3 (Niacin) M Vitamin B6 Maa 5 HPT Maa Alpha Keto Glutamate Maa Amino Acid Mix Maa Deanol


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Taking now?

VE

RY

GO

OD

GO

OD

NO

RE

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ON

SE

BA

D

VE

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NO

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Comments.

Maa Dimethylglycine (DMG) Maa DMG Maa Glutamine Maa Se (SAM, Samyr) Maa TMG Maa Tryptophan Maa Tyrosine Min Calcium Min Magnesium Min Manganese Min Selenium Min Zinc Misc Human Growth Factor Misc IV Immune Globulin Misc Kutapressin Misc Oral Immune globulin Misc Secretin IV Misc Secretin transdermal Misc Steroids Mv TTFD Oil DHA rich oils Oil EPA rich oils Oil Omega 6 rich oils Oil Omega brite Oils Cod liver oil Oils Flax Oil Other Alka Gold SEIZ Carbatrol TrA Tranxene Vir Famvir Vir Valtrex Vir Zovirax Z Z Z Z Z Z Z Z Z


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Therapies

Taking now?

VE

RY

GO

OD

G

OO

D

GO

OD

NO

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NO

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, TH

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GO

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Comments.

Acupuncture Auditory training Craniosacral EPD Homeopathy Inst. For Human Potential Lovaas Neural therapy Occupational therapy Osteopathy Speech therapy Vision therapy

Diets

Doing now

?

VE

RY

GO

OD

G

OO

D

GO

OD

NO

RE

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BA

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NO

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, TH

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Comments.

Gluten free Casein free Yeast free High protein / Low carbohydrate Feingold Salicylate free diet Low phenolics diet IgG reactive food avoidance diet Other diet: Other diet: Other diet: Other diet:


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FoodIn the past: Yes NoWere you breast fedProblem “latching on”Vigorous suckerGood suckerPoor suckerChoke or gag on milkWere you bottle fedDid you refuse to chew solidsExclusively breast-fed until _____ monthsExclusively formula fed until _____ monthsExclusively soy formula fed until _____ monthsExclusively milk based* formula until _____ monthsIntroduction of cow's milk at _____ monthsIntroduction of rice cereal _____ monthsIntroduction of wheat and other grains _____ months

*Enfamil, Similac, SMA, etc.

In the present do you eat: Yes NoA lot of ice creamA lot of sweet foodA lot of sugar/candyLarge amounts of foodOnly cold foodOnly 3-5 foods dailyA lot of cookiesA lot of white breadA lot of soda/diet sodaOnly one or two foods dailyOnly hot foodMilk at least once a daySalty foodsSensory issues with food


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Past and Present SymptomsPlease check the best description of your symptoms (mild, moderate or severe) and indicate the time frame (occasional, frequent or always). If the problem is a current and main problem, please check the “main” column. If the problem was present in the past, please check the “PAST ONLY”column.

sort Main? Symptom MILD MOD SEV Occ Freq AlwaysPAST

ONLYCOMMENT

PHYSICAL00G Double jointed00G Elongated ears00G Especially attractive00G High arched palate00G Lymph nodes enlarged elsewhere00G Lymph nodes enlarged neck00G Lymph nodes large, back of head00G Lymph Nodes tender00G Overweight00G Pupils unusually large00G Pupils unusually small00G Shiners, dark circles under eyes00G Underweight00G Unusual long eye lashes00G Webbed toes01Sta STRENGTHS A little Some Very

01Str Accepts new clothes01Str Answers parent01Str Bold, free of fear01Str Cuddly01Str Draws accurate pictures01Str Follows instructions01Str Happy01Str Likes to be held01Str Likes to be swaddled01Str Ok if parents leave01Str Perfect musical pitch01Str Physically coordinated01Str Pleasant/easy to care for01Str Pronounces words well01Str Responsible01Str Sensitive to peoples feelings01Str Sensitive/affectionate01Str Skill: arithmetic computing01Str Skill: doing fine work


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ONLYCOMMENT

01Str Skill: playing/small object01Str Skill: throw/catch ball01Str Strong desire to do things01Str Swimming01Str Unusual memory01Str Wants to be liked02Se SENSORY02Sef Fearful of harmless object02Sef Fearful of unusual events02Seg Unaware of danger02Seg Unaware of peoples feelings02Seg Unaware of self as person02Seg Very sensitive to pain02Seh Bothered by certain sounds02Seh Ear pain02Seh Ear ringing02Seh Hearing acute02Seh Hearing loss02Seh Likes certain sounds02Seh Sensitive to loud noise02Seh Sounds seem painful02Sen Covers ears with sounds02Sen Excessive ear wax02Sen Likes head burrowed02Sen Likes head pressed hard02Sen Likes head rubbed02Sen Likes head under blanket02Sen Likes to be held upside down02Sen Likes to be swung in the air02Seo Intensely aware of odors02Ses Acute sense of smell02Ses Examines by smell02Set Finger tip squeezing02Set Hates wearing shoes02Set Insensitive to pain02Sev Blinking02Sev Bothered by bright lights02Sev Distorted vision02Sev Examines by sight02Sev Fails to blink at bright light


17


ONLYCOMMENT

02Sev Likes fans02Sev Likes flickering lights02Sev Looks out of corner of eye02Sev Poor vision02Sev Puts eye to bright light or sun02Sev Strabismus (crossed eye)03Oc Adopts complicated rituals03Oc Collects particular things03Oc Corrects imperfections03Oc Draws only certain things03Oc Fixated on one topic03Oc Lines objects precisely03Oc Lines things in neat rows03Oc Repeats old phrases, sentences03Oc Repetitive play/objects03Oc Tidy03Oc Upset if things change03Oc Upset of things aren't right04B BEHAVIOR04Be Aloof, indifferent, remote04Be Behavior purposeless04Be Bites or chews fingers04Be Bites wrist or back of hands04Be Climbs to high places04Be Constant movement04Be Curious/gets into things04Be Destructive04Be Does opposite/asked04Be Extremely cautious04Be Falls gets hurt running climbing04Be Head banging04Be Holds hands in strange pose04Be Hyperactive04Be Imitates others04Be Lost in thought, unreachable04Be Melt downs04Be Poor focus, attention04Be Poor sharing04Be Silly04Be Spends time with pointless task


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ONLYCOMMENT

04Be Tantrums04Be Toe walking04Be Uninterested in live pet04Be Unusual play04Be Uses adults hand for activity04Be Watches television long time04ben Doesn't do for self04ben Hides skill/knowledge04ben No purpose to play04ben Rejects help04ben Teases others04ben Tries to control others04ben Unable to predict actions04ben Won't attempt/can't do04Bes Eye contact poor04Bes Finger flicking04Bes Flaps hands04Bes Jumps when pleased04Bes Licking04Bes Likes spinning objects04Bes Likes to flick finger in eye04Bes Likes to spin things04Bes Rhythmic rocking04Bes Sits long time staring04Bes Slapping books04Bes Stares at own hands04Bes Tooth taping04Bes Whirls self like a top04Bes Wiggle finger front of face04Bes Wiggle finger side of face04Bew Insists on what wanted04Bew Lacks initiative04Bew Runs away05B0V Headaches05B0V Joint pains05B0V Leg pains05B0V Muscle pains05bo Arched back with bright lights05bo GENERAL05bo Holds bizarre posture


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ONLYCOMMENT

05bo Perspiration - odd odor05bo Feet - stinky05bo Physically awkward05bo Seizures – focal05bo Seizures – generalized05bo Seizures – petit mal05bo Seizures – petit mal05bo Stiffens body when held05bo Unusual physical pliability05bo Unusual sound of cry05BOA Abnormal fatigue05BOA Moaning05boe Conjunctivitis05boe Eye crusting05boe Eye problem05boe Lid margin redness05BOH Heart murmur05BOH Mitral valve prolapse05BOH Unusual fast heart beat05Bot Cheek/ear - pink/cold05Bot Cold all over05Bot Cold hands and feet05Bot Cold intolerance05Bot Hands/feet - very sweaty05Bot Head very hot/sweaty05Bot Night sweats05Bot Tip nose - pink/cold06L COMMUNICATION06La Answers by repeating question06La Asks using "you" not "I"06La Babbling06La Does not asks questions06La Expressive language poor How many words?____06La No answers simple questions06La Points to objects/can't name06La Receptive language poor06La Says "no"06La Says "yes"06La Says “I”06La Scripting


20


ONLYCOMMENT

06La Talks to self06La Uses one word for another07mo Always frightened07Mod Anxiety07Mod Inconsolable crying07Mod Negative07Mod Phobias07Mod Severe mood swings08S SLEEP08Sl Sleeps in own bed08Sl Sleeps with parent(s)

Awakens screaming/crying08Sl Awakes at night08Sl Daytime sleepiness08Sl Difficulty falling asleep08Sl Early waking08Sl Nightmares08Sl Sleeps less than normal08Sl Sleeps more than normal09DA Abnormal food cravings09DA Pica (eating non-edible things)09DA Always thirsty09DA Behavior worse with food09DA Bingeing09DA Bread craving09DA Carbohydrate intolerance09DA Chew or swallow nonfood09DA Craving for carbohydrates09DA Craving for juice09DA Craving for salt09DA Diet soda craving09DA Poor appetite09DA Sweets before food09DA Unusual/extreme water drinking09DI DIGESTION & FOOD:09Dig Abdominal bloating09Dig Abdominal pain09Dig Burping09Dig Colic09Dig Constipation


21


ONLYCOMMENT

09Dig Cracking lip corners09Dig Diarrhea09Dig Farting – regular09Dig Farting – stinky09Dig Fissures09Dig Geographic tongue (map-like)09Dig Gums bleed09Dig Intestinal parasites09Dig Lower abdominal bloating09Dig Mouth cold sores09Dig Mouth thrush (yeast infection)09Dig Nausea09Dig Pinworms09Dig Red ring around anus09Dig Reflux09Dig Sore throat09Dig Sore tongue09Dig Spitting up09Dig Stools bulky09Dig Stools light color09Dig Stools very stinky09Dig Stools with blood09Dig Stools with mucous09Dig Stools with undigested food09Dig Teeth grinding09Dig Upper abdominal pain09Dig Vomiting10Res RESPIRATORY:10Resp Bad odor in nose10Resp Breath holding10Resp Bronchitis10Resp Congestion chg. season10Resp Congestion in the fall10Resp Congestion in the spring10Resp Congestion in the summer10Resp Congestion in the winter10Resp Cough10Resp Pneumonia10Resp Post nasal drip10Resp Sighing


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ONLYCOMMENT

10Resp Sinus fullness10Resp Wheezing10Resp Yawning

SKIN:11SKI Acne11SKI Athletes foot11SKI Blotchy skin11SKI Bugs love to bite you11SKI Cellulite11SKI Chicken skin11SKI Cradle cap11SKI Dark birth mark(s)11SKI Dark circle under eyes11SKI Diaper rash11SKI Ears get red11SKI Easy bruising11SKI Eczema11SKI Flushing11SKI Inability to tan11SKI Light birth mark(s)11SKI Odd body odor11SKI Oily skin11SKI Pale skin11SKI Patchy dullness11SKI Red face11SKI Seborrhea on face11SKI Sensitive to insect bites11SKI Stretch marks11SKI Strong body odor11SKI Thick calluses11SKI Vitiligo12It ITCHING OF:12itc -Anus12itc -Arms12itc -Ear canals12itc -Eyes12itc -Feet12itc -Hands12itc -Legs12itc -Nose


23


ONLYCOMMENT

12itc -Penis12itc -Scalp12itc -Skin in general12itc -Vagina13D HAIR, SKIN, NAILS13DA Dandruff13DA Dry Hair13DA Dry Scalp13DA Dry skin in general13DA Feet cracking13DA Feet peeling13DA Hair Unmanageable13DA Hands cracking13DA Hands peeling13DA Lackluster skin13DA Lower legs dry13Drn Bites nails13Drn Fungus / fingernails13Drn Fungus / toenails13Drn Nails brittle13Drn Nails frayed13Drn Nails pitted13Drn Nails soft13Drn Ragged cuticles13Drn Thickening finger nails13Drn Thickening toenails13Drn White spots or lines

14Mu MUSCULAR:14Mus Calf cramps14Mus Foot cramps14Mus Muscle pain14Mus Muscle tone tense14Mus Muscle twitches14Mus Poor muscle tone/limp14Mus Tics15R REPRODUCTIVE:15Re Age of first period ______15Re Boys: Large testicles


24


ONLYCOMMENT

15Re Early onset breast development15Re Early onset pubic hair16U URINARY:16Ur Bed wetting after age 416Ur Odd urinary odor16Ur Urinary hesitancy16Ur Urinary tract infections16Ur Urinary urgencyP00G PallorZz

Environmental History (please indicate past and present exposures)

Some things about your parents:

Exposure: Past Present When were your parents married:

Mold in bathroom If separated, when:Damp cellar If divorced, whenPest extermination - Inside If remarried, whenPest extermination - Outside Custody arrangementsForced hot air heat Mother - PersonalHad water in basement Age at your birthMold visible on exterior of house EducationHeavily wooded or damp surroundings EthnicityMold in cellar, crawl space, or basement Blood typeMoldy, musty school/daycare Father - PersonalTobacco smoke Age at your birthWell water EducationCarpet in bedroom EthnicityCarpet in most parts of house Blood typeFeather or down bedding


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Mother’s Side Father’s Side

Family Medical History

Father

Mother

Sibling(s)

Grand-

mother

Grand-

father

Grand-

mother

Grand-

father

First C

ousin

Other

AlcoholismAllergiesAnorexiaAnxietyArthritisAsthmaAutismAutoimmune problemsBulimiaCeliac diseaseColitisCrohn’s diseaseDepressionDiabetesEczemaEndometriosisFood allergiesGout/high uric acid levelHay FeverHeart diseaseHigh blood pressureHivesHypoglycemiaIdentical twinsIrritableLeft handednessMalabsorptionMental IllnessMild respiratory allergyMilk (casein) sensitivityMitral valve prolapseObesityRetardationSchizophrenia PsychosisStrokeStrong moodinessTendency to be" loner"Thyroid problemWheat (gluten) sensitivityYeast problems

Thank you for taking the time and effort to complete this questionnaire. We suggest you make copies of it for your records.


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Documents

Dr. Sidney M. Baker · Web viewQuestionnaire for Children with Autism & Related Developmental and/or Attention Problems (Adapted from ARI Questionnaire c/o Sidney M. Baker, M.D.)