MEET . SHARE . EMPOWER
Registration for a introductory interaction to learn and understand more about ASD from Biomedical or Functional and Integrative Medicine’s perspective
Email *
Child's Name *
Father's Name *
Father's Phone Number *
Mother's Name *
Mother's Phone Number *
Alternative Email Id *
What is/do you suspect is the diagnosis of the child? *
How old is your child? *
When did you first notice any changes in him/her? *
Have you tried any interventions till now? Yes or No *
If yes, what interventions have you tried and for how long? If No, then write none *
Did you see any benefits or negative effects from the interventions you tried? Please list them?           *
Intervention benefits              negative effects/consequences
What type of diet do you give your kid? Have you tried any other diets and please list any benefits or negatives that you have seen with them?                                                       *
Diet                           benefits               negative effects/consequences
Have you tried any supplements with your child? If yes, how long have you tried them for?                             *
Supplements                benefits                    negative effects/consequences
Did the child have issues from birth or did the child regress later? *
If the child regressed, when was the last time your child was well? *
What do you suspect is the cause of the regression? *
Did you have any complications during pregnancy? *
Did you have any complications after delivery? *
Did the mother breastfeed the baby and for how long? *
Did you ever use formula? What age did you start the formula feeding? *
Is there anything that weighs you down the most or stresses you the most? *
Do you feel helpless or frustrated about anything? *
Do you feel you might benefit or be helped from any particular information? *
Do you have any coping up measures when you are frustrated or stressed out? *
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