BioEnergyMedicalCenter3131ProfessionalDriveAnnArbor,MI48104

(p)734-995-3200(f)734-995-4254PEDIATRICPATIENTINITIALCONTACTFORM:Pleaseindicateyourinterestinbeingevaluatedby

BioEnergyMedicalCenter/Dr.Neuenschwanderandbecomingapatientofthepracticebycompletingandsigningtheformbelowandreturningittotheaddressabove.PleasenotethatBio

EnergyMedicalCenterisaspecializedconsultationbasedpracticeandyoumustmaintainaseparateprimarycarephysicianforyourchild’sgeneralhealthcareneedsandfollow-up.

AppointmentDate:_____________________Time__________________Today’sDate_____________

Mother’sName:______________________________________________________________________________

Father’sName:_______________________________________________________________________________

Street:_________________________________________________________________________________________

City:_________________________________________State:_________________Zip:___________________

HomePhone:______________________________CellPhone______________________________________

EmailAddress_______________________________________________________________________________

Child’sName:____________________________________________Sex:___________Age:_____________

InordertoscheduleanewpatientpediatricconsultationwithDr.Neuenschwander,youmustsendthefollowingitemstotheaboveaddressoremailpaperworktodrneu@bioenergymedicalcenter.com.Oncepaperworkanddepositareobtained,youwillbecontactedbyourofficetoscheduleanappointment.

• ThisPediatricPatientInitialContactForm–whichMUSTbesignedbyBOTHparents• Acheckforthe$150refundabledeposit(ifappointmentcancelledwithmorethan7days’notice),

madepayabletoBioEnergyMedicalCenter• ThePracticePolicy–formMUSTbesignedbyBOTHparents• AcompletedPediatricPatientQuestionnaire

Thefeeforyourinitialconsultationis$450.00(lessthedeposit)andincludes:• Comprehensivereviewofyourchild’shistoryandquestionnaire• ConsultationwithDr.Neuenschwanderforapproximatelytwohours• Treatmentoutlineandrecommendations• Effective January 1, 2014 Dr. Neuenschwanderwill no longer submit to insurance, youwill be

providedareceiptthatcanbesubmittedforpossiblereimbursement.Sign___________________________________________________Date____________________Sign____________________________________________________Date_____________________

BioEnergyMedicalCenter3131ProfessionalDriveAnnArbor,MI48104

734-995-3200

PRACTICEPOLICIESOFFICEPOLICY:

Werequireacreditcardnumberonfileforallpatientsinordertoscheduleappointments.Tobeconsideredanactivepatientandreceiveongoingcare,werequirethatachildbeseeninourofficeatleastoncepercalendaryear.Allotherfollow-upappointmentsmaybeinpersonorbytelephone.

CANCELLATIONPOLICIES:

As part of our continued effort to provide you with the very best medical care and toaccommodate allappointmentrequests,wearerequiringavalidcreditcardbeonfiletoreserveyourtimewithourclinicians.Ourcliniciansmeticulouslyprepareforeachappointmentpriortothetimeofyourappointment.Thisensuresthatweachieve the high standard of care and treatment we pride ourselves on. All services are provided byappointmentonlyandthisscheduledtimeisreservedforyourexclusiveuse.Thecancellationpolicydiffersbythetypeofappointment,asdocumentedbelow.

CancellationofanInitialConsult

Allnewpatientappointmentsmustbecanceled7dayspriortoyourscheduledappointment.Appointmentsnotcancelledwithin7daysofthescheduledappointmentwillbebilledat50%ofthestandardinitialconsultationfee.

Follow-upAppointmentCancellation

We require two business day’s notice for follow-up consultations, which includes office visits or telephoneconsultswithanyofourclinicians.Appointmentsnotcancelledtwobusinessday’softhescheduledappointmentwill be billed at100% of the standard fee for the follow-up service.Fees for non-cancellation of follow-upappointmentsarenon-refundableandmaynotbeusedascredittoafutureconsultationorprocedure.

Tocancelanappointment,pleasecall734-995-3200.OurgeneralofficehoursareMondaythruThursday,9a.m.-5p.m.Allcancellationsmustbestatedviatelephone.Ifyoucannotreachusinpersonbyphone,youcanleaveadetailedvoicemailmessagewithyourname,patient’sname,dateandtimeofyourscheduledappointment.InthecaseofatruemedicalemergencyoranactofGod(naturaldisaster)ourcancellationpolicydoesnotapplybutmayrequiredocumentationinwriting.Ifyouhaveanyquestionsregardinganyofthesepolicies,pleasecallourofficeat734-995-3200.Yourcooperationandunderstandinginthismatteraregreatlyappreciated.

I/WE ________________________________________________________________ have read and understand theaboveoutlinedpolices.

Parent/GuardianSignature_____________________________Date____________________________

Parent/GuardianSignature_____________________________Date____________________________

Autismspectrumdisorder (ASD)coversarangeofabnormalities. Ononeendof thespectrumis theseverelyautistic(“Rainman” type) patient; while on the other is a person with attention deficit disorder (ADHD). Persistentdevelopmentaldelay(PDD)andAsperger’sSyndromelieinbetween.Therehasbeenarapidandconcerningincreaseinthe incidenceofASD to thepointwhereone in 50 childrenbornwill bediagnosedwithASD. The incidence is evenhigherinmales.TherehasbeenmuchworkinthefieldofgeneticstoidentifyanomaliesthatmaycauseASD.Sofar,overonehundredgeneticanomalieshavebeenidentifiedthatarelinkedwithASD.However,ifgeneticswerethesolecause of ASD,wewould not see the alarming rise in its incidence. The rate of a solely genetic disorder should stayconstant over time. There is a much more sophisticated understanding of the relationship between genes andenvironmentthathascometotheforefront—afieldcalledgenomics.Genomicsrecognizesthatthegeneticblueprintisonly a set of possibilities; it is the interaction of those genes with the environment that determines how a persondevelops.Withthisinmind,anumberofpioneeringphysiciansandresearchscientistshavebeenlookingatASDtofindwhatenvironmentalfactorsmayplayaroleinthedevelopmentofASDandwhethermanipulatingthesefactorscouldreversetheprocessandactuallycureachildwithASD.Thisisknownasthebio-medicalapproachtothetreatmentofASDandhas been championedby groups such asDefeatAutismNow! (previously knownasDAN!) and TheMedicalAcademyofPediatricSpecialNeeds(MAPS).ThisapproachiswhatweuseatBioEnergytotreatourpatientswhohavebeendiagnosedwithASD.

Thefirstareofinterestliesinthedigestivetract.Ithasbeenknownsinceautismwasfirstdescribedthatmostofthesechildren have issueswith their digestion. These range from simple stomach upset and bloating to severe, explosivediarrhea.DietarychangesfrequentlyarethefirststepintreatingASD.Approachesincludeaglutenandcaseinfreediet,a rotation diet, a specific carbohydrate diet, or a low oxalate diet. Gluten and casein are proteins found in grains(especially wheat) and dairy, respectively. They appear to be an issue of ASD children on two fronts. First, manychildrenhavedelayed-typehypersensitivity to theseproteins—inessence, theyareallergic to them. Secondly, theseproteinsarebrokendownintointermediatesthatactlikeopiates—alteringbehaviorandcontributingtothechildren’sseparationfromtheirenvironment.Over60%ofASDchildrenimprovedwiththisdietalonebasedonparentreporting.The rotation diet is based on a child’s individual food sensitivities. Weperformblood testing to determine a child’ssensitivity profile andmake recommendations on these results. The specific carbohydrate diet can aid children thathave issueswith intestinal candidiasis (yeast)or sugar sensitivities. The lowoxalatediet canbehelpfulwithchildrenthat remain agitated despite other interventions or if there is any evidence of joint problems. If this soundsoverwhelming,don’tworry.Wetrytotailorachild’sdiettohisorherspecificissuesbasedonhistory,observation,andsometesting.

The second area of importance for children with ASD is the arena of methylation and sulfation. These describebiochemical processes that are essential for detoxification and energy production. Children with ASD appear to bedeficientinoneorbothoftheseareas.Becauseofthis,theyaremuchmoresensitivetoenvironmentaltoxinsthanareunaffectedchildren. Ifanunaffectedchild ispresentedwithanenvironmentaltoxinsuchasapesticideresidue,theirsulfationmechanismswith take care of the problem. A childwith ASD that has a problemwith this systemwill beunabletoprocessthesametoxinwithoutcausingotherproblems.TheASDchildwillhaveto“robPetertopayPaul;”methylationandsulfationcomponentswillbestolenfromenergyproductioninordertoassistwithdetoxification.Thenetresultwillbeacellthatcannotfunctionproperly.Thebrainisparticularlysensitivetothisprocess.Ifthesechangesoccurinanadult,theywillexperience“brainfog”andfatigue.Iftheyoccurinachildwithadevelopingbrain,theywillresult indelayedorregresseddevelopmentandbehavioralproblems.Treatmentinvolvesidentifyingthetoxinsinthechild’s environment, removal of those toxins from both the environment and the child, and nutritional support topromoteor supplement these systems. Muchof thebiochemical testingwedoatBioEnergy isdesigned to identifythesetoxinsandmetabolicabnormalities.

A thirdareaof concernwithASDchildren is the immunesystemand the syndromeof chronic infections. ManyASDchildren have problems with recurrent infections with strep or other common organisms. One recent studydemonstratedalmost60%ofASDchildrentestedpositiveforMycoplasma(acommonatypicalbacterialinfection)whileonly5%ofunaffectedchildrentestedpositive. Apositiveornegativeresultwasbasedonthepresenceorabsenceofthe bacterial DNA in the child’s blood using an extremely sensitive technique called PCR. Therewere similar resultswhenthesechildrenweretestedforChlymadiapneumoniaandHumanHerpesVirus6.ThiswouldsuggestthatsomepartoftheASDchild’simmunesystemisnotfunctioningproperly.Inaddition,manyASDchildrenhaveabnormalstoolculturesshowingmanypotentiallydiseasecausing(pathogenic)organismsaswellasa lackofhealthybacteria. Thereareanumberofstoolandbloodteststhatweperformtotrytoidentifyandtreattheseorganisms.

Another issuewithASDchildren isheavymetal treatmentwithchelation. ManyASDchildrenhaveelevated levelsoflead,mercury, andother toxicmetalswhen testedappropriately. A largepercentageof childrenwithASDwill showimprovementwithchelation(theprocessofremovingthesemetalsusingcompoundsthatbindthemandremovethemfrom the body). Most chelators we use also have the added benefit of being excellent supporters of the sulfationprocesseswediscussedearlier.AtBioEnergy,weusebothurinechallengetestingaswellashairanalysistodeterminewhomight benefit from chelation therapy. Children that demonstrate issues with sulfationmay also be prescribedchelationinanefforttoimprovethatfunctionaswell.

Finally,awordon“traditional”treatmentofASD.NothingwedoatBioEnergyinthetreatmentofASDisintendedtoreplace the usual ABA, PT/OT/Speech therapies of traditional medicine. At the end of the day, ASD children haveproblemsprocessing their environment. Theyneed tobe taught themostbasic issuesof life, social interaction, andappropriatebehavior.Thebiomedicalapproachesareintendedtoallowthislearningtooccur,notreplacetheprocessofteaching.Thesameistrueofmedications.Wewilldoeverythingwecantoidentifyandcorrectreasonswhyachildisagitatedandmisbehaving;however,sometimesmedicationistheonlywayforachildtocalmdownenoughtolearn.

WestrivetobethoroughinourapproachtothechildwithASD.Thisbeginswithparentsfillingoutathoroughhistoryofthechild’sdevelopment,history,andprevioustherapiesthathavebeentried.Weaskthatthisbedoneafewweeksinadvance of the initial evaluation so that Dr. Neuenschwander can read it in advance. The actual appointment isscheduledfortwohours.ThiswillallowDr.Neuenschwandertogetacompletehistoryandobservethechildinaction.Based on these ingredients, Dr. Neuenschwander will recommend further testing and or dietary changes andsupplements.

BioEnergyMedicalCenterJamesNeuenschwander,M.D.

3131ProfessionalDriveAnnArbor,MI48104

January,2017

PATIENTCONSENTFORMToWhomItMayConcern:May I ask that you sign a copy of this document and return it to Bio Energy Medical Center? Your signature willdocumentyourunderstandingandconsentofthefollowingprinciplesandpractice.TherehasbeenarisingincidenceintheUSandelsewhereofproblemsinchildrenthatfalldiagnosticallywithinaspectrumofautisticdisorders(ASD)andpossiblyrelatedattentionproblems(ADHD).TotheextentthatanyindividualdisplayssymptomsofASDandADHD,heorshemaybeaparticipantintherisingincidenceoftheseproblems.Totheextentthattheseproblemsareincreasinginincidencebeyondanymeasurethatcouldbeattributedtoapurelygeneticcause(whichwouldbestable in incidenceoverlongperiods)anyparticipantintheincreasemaybeassumedtohavecausesconsistentwithenvironmentalfactors.BasedonsuchconsiderationsIwouldliketohavesuchcausesconsideredintheevaluationofmychild.In asking Dr. Neuenschwander for help in optimizing the options for my child I have been aware that my child’ssyndrome includesmany features that are not necessary to diagnoseASDorADHD in a given child andmay includesymptomsrelatedtootherbodysystemsthanbehavior,cognitionandsocialization.Thesesymptomsareindicatedonthequestionnaireandotherdocumentsintroducedattheinitialvisit.IwasnotseekingatreatmentorcureforadiseasesuchasAutism,butratheranapproachfocusingonmychildasanindividual. Istheresomethingofwhichthispersonshouldberid,whichwouldresult inbetterfunction?Iunderstandthatasamatterofpublicpolicy,noenvironmentalcausehasbeenproven linktoASDorADHDorrelatedproblems inchildrenoradults. Igraspthedifferencebetweenpublic and private health policy and insist that the threshold for reasonableness in decisions applied to any givenindividualmaybelowerthanthatrequiredforproofasappliedtolargegroupsofindividuals.MoreoverIinsistthatmychildbetreatedasanindividual,notsolelyonthebasisofhisorherdiagnosticgrouping.Therefore,borrowingfromalistofpossibleenvironmentalfactorsthathavebeensuggestedascausativeoftheriseofincidenceinASD,ADHDandpossiblyrelatedproblemsIdesirethatsuchfactorsbeconsideredintheinvestigationofthebiochemical,immunologicalandtoxicologicalaspectsofmychild’sproblems.IamfamiliarwithwritingsorthecontentsofwritingsthatdescribethefactorsassociatedwiththeriseinincidenceofASDandrelatedproblems.TheseincludetheNewslettersoftheAutismResearchInstitute,BiomedicalAssessmentOptionsForChildrenwithAutismandRelatedProblems,byPangborn,JandBaker, SM. Publishedby TheAutismResearch Institute, Biological Treatments forAutismandPDD, byWilliam Shaw,PhD, Children With Starving Brains: A Medical Treatment Guide for Autism Spectrum Disorder, Second Edition, byJaquelynMcCandless,MD,thesyllabiofthemeetingsoftheDefeatAutismNow!(DAN!)Organization,TheChemistryofAutism,byBaker,SMetallpresentedattheAutismResearchInstitute™DefeatAutismNow!ConferenceinPhiladelphiaPA,April2008,aswellasvariouspostingsonthe Internetthatrefertothequestionsandtheoriesexpressed inthesewriting.Idesirethatmychildbeevaluatedwithdiagnosticstepsaimedatsomeorallofthefollowingfactorsthatarereferredtointheabovepublicationsorinthereferencescitedbythem.Thesefactorsincludepossibleresponsivenessto:Nystatin,Sporanox,Nizoral,Diflucan,Lamisil,oralamphoteracinB,Saccharomycesboulardii,andotheroverthecounterantifungalsubstances.

• Dietexcludingyeasts,molds,andsugars• Dietexcludingcaseinandgluten• Dietexcludingstarches(SpecificCarbohydrateDietasdescribedinBreakingtheViciousCycle

• Administrationofvarioussulfurbearingsubstancesthatarebroadlyconsideredtobeusefulinthedetoxificationofheavymetalsbutmayalsobeeffectiveinprovidingsupporttothechemistryofsulfationinitsotherrolesinhumanbiochemistry.Thesecompoundsare reducedgluthatione, thiamine tetrahydrofurfurlydisulfide (TTFD),andalphalipoicacid,nacetylcysteine,andEpsomsaltbaths.

• Vitaminandmineralsupplements• Supplements of certain amino acids, which may, depending on diagnostic evidence, address problems of

maldigestion of proteins, malabsorption of essential amino acids, abnormalities of precursors ofneurotransmitters,anddeficitsofsulfuraminoacids.

• Supplementsofomega3oils• Methylcobalmin(methylB12)• Folicacid,folinicacid(leucovorin),5methyltetrahydrofolate(Folapro)• VitaminB6andMagnesium• Acyclovirorrelatedantiviralcompounds• Probiotics• Oraltransferfactor• Digestiveenzymes• Oralimmuneglobulin• IntravenousImmuneglobulinifIrequestreferraltoadoctorwhogivesit.• Secretin

Iunderstandthatnoneoftheaboveconstitutestreatmentforadiseasebutineachcase,ifadministeredtomychild,isadiagnosticmeasuredesignedtodetermineeffectiveness.Onlyonthebasisofinitialpersuasiveevidenceofeffectivenesswould any of these measures constitute more than a diagnostic test. I understand that the judgment of sucheffectivenessmaybe basedon changes in signs, symptoms and laboratory tests. I further understand that there arescientificallyplausiblelinksimpliedamongthevariouscausativefactorsintheabovelistandthatcombinationsofthesemeasuresmaybehelpfulwhen singlemeasuresmay fail. I understand that inmy child’s record,where anyof thesemeasures is listed in a section labeled treatment that the measure constitutes a therapeutic trial and as such is adiagnostic test of efficacy. I understand that essentially all of the above factors have been declared unproven. Iunderstandthatessentiallyalloftheabovefactorsmaybeconsideredunprovenorexperimentalbythirdpartypayers.My acknowledgement below constitutes my consent to the diagnostic approach embodied in this document. Anyspecificmeasurestakenhavebeenorwillbecarriedoutbymeorundermysupervisionasaparent.Totheextentthatsome of the diagnostic approaches embodied in this document have already been undertaken in my child’s care Iacknowledge that my understanding of the approaches at the time of first considering each of these steps wasessentiallynodifferent thanat the timeof signing thisdocument.Atno time in thecourseofmychild’scaredidDr.Neuenschwanderlackmycompletelyinformedconsent.ParentPrint_____________________________ParentSign_________________________Date_____________ParentPrint_____________________________ParentSign__________________________Date______________HIPAAConsentIamawarethatadocumentcontainingmyprivacyrightsundertheHIPAAlaws isavailable intheBioEnergyMedicalCenterwaitingroomshouldIwishtoreviewit.Bysigningthisdocument,IamsignifyingthatIunderstandandagreetoitsprovisions.Parent:____________________________________________Date________________________________

BioEnergyMedicalCenterJamesNeuenschwander,M.D.

3131ProfessionalDriveAnnArbor,MI48104

April2016

"English”VersionofPatientConsentForm

The intent of this consent is to be clear on Bio Energy Medical Center’s approach to the biomedicaltreatment of children diagnosed with autism spectrum disorder (ASD), attention deficit (ADHD), orrelateddisorders.Thesalientpointsoftheconsent(inplainEnglish)are:

• The “standard” model of ASD is that it is a genetically programmed psychiatric disorder.Therefore, the only treatment is to use behavioral/cognitive techniques and psychiatric medications.Even though the original description of autism includedmanyphysical symptoms, these are felt to beunimportantinthetreatmentofASD.WhileDr.Neuagreethattherearemanygeneticcomponentsthatare at play inASD and related disorders, themanifestation of these geneticmutations are affected byenvironmentalfactorsinthevastmajorityofchildrenwithASDandrelateddisorders.

• Weaskthatparents/caretakersbesomewhatfamiliarwiththebiomedicalapproach.Anumberofbooks/referencesare listed. Wedonotexpectyou to readandmemorizeall these sources. Theyarelistedsothatyoucanbecomeinformedpriortoyourvisit.

• ThetreatmentprotocolsusedbyDr.Neuarelisted. Noneofthetreatmentsareacceptedbythe“powersthatbe”inpediatricsastreatmentsforASD.Thesetreatmentsareusedbothdiagnosticallyandtherapeutically.Althoughwehavemanytestsatourdisposal,frequentlytheonlywaytodetermineifatreatment will be helpful is to try the treatment first (diagnostic trial). If it helps, we continue thattreatment(therapeuticuse).

• Theprotocolsmentionedarealwaysinadditiontothebehavioralandcognitivetreatments. WedonotcurrentlyofferthesetypesoftreatmentsatBEMC.

• Finally, theconsentmentions thatany treatments thatareundertakenprior toofficiallysigningtheconsentaredonewiththeelementsoftheconsentforminplace.

Ifyouhaveanyquestionsabouttheconsentformorourapproach,pleasedonothesitatetocontactusattheabovenumbers.

Page 1 Office Use Only

CK CA CC

PERSONAL INFORMATION Date Questionnaire Received: ____ / ____ / ____ Date of Initial Consultation: ____ / ____ /

[The above line is for office use only]

Child’s Name: First: Last: Middle Initial: Parent(s) Name(s):

Address: Street: City: State: Zip: Phone: ( ) Cell # :( ) Email:

Child’s birth date: Month: Day: Year: Child’s Sex (Circle One): Male/Female Responsible Party’s Social Security Number (If billing insurance): — —

Primary Care Physician: Name: City: State: Zip: Phone #: ( ) Cell #: ( )

Health insurance: Phone #: Group# ID #:

Subscriber’s Name: Subscriber’s Date of Birth:Siblings: Name: Sex Birthdate

Male/Female Month: Day: Year:

Male/Female Month: Day: Year: Parent’s occupation(s):

Note: Please bring a fairly recent picture of your child that we may keep plus a baby picture that we may look at and return.

Diagnoses or explanation given to you about your child (Date of diagnoses: _____/_____/_____) :

Other problems to be addressed:

BioEnergyMedicalCenterJamesR.Neuenschwander,M.D.3131ProfessionalDriveAnnArbor,MI48104734-995-3200fax734-995-4254

Page 2

PERSONAL INFORMATION (Continued) Describe your child to me, including his/her history. Please be as detailed as possible.

• When did you first notice your child’s problem?

• What did you first notice? • Was the onset of your child’s problem sudden or gradual? • Was there any event or illness that you or others think brought on your child’s symproms?

Please make notation of any other event, action, etc. that you think may have some bearing/ relationship to your child’s condition. Again, be as detailed as possible and do not hesitate to mention anything, no matter how small or insignificant, that you believe is related to your child’s problem(s):

Page 3

CHILD’S MEDICAL HISTORY PRIMARY DOCTOR (S)

Name Phone Numbers City

THERAPIST(S) Speech - Occupational - Physical - Other

Name Type of Therapist Phone City Hours/Week

Other Care-Givers

Name Phone City Date of Evaluation

Specialist(s)

Naturopath(s)/Homeopath(s) Nutritionist

Other

Page 4

PRENATAL HISTORY Maternal age at delivery: _________ years

Illnesses during pregnancy: Medication/Vaccines during pregnancy including flu vaccine:

Dental work during pregnancy?

Complications during pregnancy: Complications during labor and delivery:

Mode of delivery: C-section/vaginal? If C-section, explain why: If vaginal delivery, did you have forceps/vacuum?

Medication(s) during labor and delivery? Full term/premature? (Circle one) How many weeks? ________ weeks

Complications after delivery?

Medications given to child during hospital stay?

Page 5

DIETARY/NUTRITIONAL HISTORY Breast-fed? Yes/No (Circle One): If yes, how long? _________ Bottle-fed? Brand of formula? ___________ Begun at what age? _______ For how long? ___________

Foods? Begun at what age? First foods? _____________________________________

Whole milk? Yes/No (Circle One) If yes, begun at what age? _______ Known allergies to food? (Please list): ______________________________________________________

Suspected sensitivities to foods? (Please list): ______________________________________________

Food cravings? (Please list): ______________________________________________________________ Foods my child eats: (Place 3 in appropriate column)

3 - 5 times/ 1 - 3 Never or Used to eat a lot Food Daily week times/ almost never but no longer does

week

Cookies: Candy:

Sweet foods: Caffeine (soda, tea, etc.):

Chocolate:

Milk: Whole:

2 % : 1 % : Skim:

Cheese: Ice Cream: Salty Foods: Meat: Pasta:

Bread: White: Wheat:

Other:

Page 6

DIETARY/NUTRITIONAL HISTORY (Continued) Check (3) the most appropriate description below of your child’s diet: Mostly

baby foods

Mostly carbohydrates (bread, pasta, etc.)

Mostly dairy (milk, cheese, etc.)

Mostly meat

Mostly vegetarian (vegetables, fruits, grains, etc.)

Other. Describe: Please describe your child’s stool pattern (Examples: daily, foul, large, mushy, etc.):

Please list the foods and beverages normally consumed by your child for three typical days: DAY 1

Breakfast: Morning snack(s):

Lunch:

Afternoon snack(s):

Dinner: Other

DAY 2

Breakfast:

Morning snack(s): Lunch:

Afternoon snack(s): Dinner:

Other DAY 3

Breakfast:

Morning snack(s): Lunch:

Afternoon snack(s): Dinner:

Page 7

FAMILY HISTORY List any allergies, major illnesses, genetic diseases or problems for each of the following family members of your child: Mother: Father: Siblings: Maternal Grandparents: Paternal Grandparents: Others:

SOCIAL HISTORY Who lives in the home with your child:

Are any children in your family adopted?

Pets in the house:

Caregivers besides parents:

List the people most important in your child’s life: Recent changes, losses, births, deaths, divorce, remarriage or moves: Recent travel:

Child’s response to these changes:

Is your child involved in any sports, music or other activities? Please describe: How does your child interact with other children?

• With adults:

•What makes your child happy?

•Sad?

•Angry?

•Stressed?

•How do you as a parent deal with these emotions in your child?

Page 8

ENVIRONMENTAL HISTORY Do you, your child, or any family members practice any relaxation/stress management techniques? Please describe:

CIRCLE THE APPROPRIATE ANSWERS TO THE FOLLOWING QUESTIONS:

Location of home: City/Suburban/Wooded/Farm Other (describe): Water: City/well Purification system: Yes/No If yes, please describe:

Type of heat: Electric/gas/oil/other If other, please describe:

Do you live near: Power lines/woods/industrial areas/water?

If you live near water, list type: Swamp/river/ocean/other If other, please describe:

Does your home have a lot of: Dust/mold/down or feather items (pillows, upholstery, stuffed animals?) If, so, please give details: Describe your child’s bedroom (Circle appropriate response):

Bedding: Synthetic/down/feather? Mattress cover: Yes/No Crib/Junior Bed/Adult Bed

Flooring: Carpet: Wall-to-wall or area rug? Wood? Glued down? Synthetic pad?

Window treatment: Shades/blinds/thin curtain/heavy curtain/valance/other? If other, describe: Other items in room including furniture, toys, stuffed animals: Flooring in other rooms:

Child’s bathroom?

Living room?

Family room/play room?

Is your child sensitive to or bothered by any of the following? Please check where appropriate and list specific products if possible:

Perfumes/cosmetics? Mold?

Cleaning products? Pollens/grasses?

Soaps? Animals (dander)?

Detergents? Gasoline?

Dust? Paint?

Other?

Please list known allergies:

Page 9

DEVELOPMENTAL HISTORY Please list age when following skills were mastered and any problems associated with these skills: First

words: (Age: _____ ) Phrases or sentences: (Age: _____ )

Pulling to stand: (Age: _____ )

Walking: (Age: _____ )

Sitting up: (Age: _____ )

Crawling: (Age: _____ )

Running: (Age: _____ )

Walking up/down steps without help: (Age: _____ )

Jumping: (Age: _____ )

Learned to pedal: (Age: _____ )

Rode 2-wheel bicycle: (Age: _____ )

Put on clothing: (Age: _____ )

Page 10

MEDICAL HISTORY Please mark which tests have been done and provide date and results

Evaluation/Test Date Results (normal, abnormal or unsure)

24 Hour Amino Acids

Amino Acid Screen

Blood Chemistry Screen

Blood Count (CBC)

Blood Test—Fatty Acid

Blood Test—Food Allergies

CT Scan (specify area)

Colonoscopy

DMSA Loading Study

EEG

Folic Acid

Fragile X Chromosome Study

Hair Elements

Hearing Test

Immune Profile

Intestinal Permeability

Liver Detox Profile

MRI (specify area)

Organic Acids—fungal/bacteria

Organic Acids—Metabolism

PET Scan

Page 11

MEDICAL HISTORY Please mark which tests have been done and provide date and results

Evaluation/Test Date Results (normal, abnormal or unsure)

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 (blood or urine)

Urinary Peptides

Urine Elements

Urine Kryptopyrrole

X-Rays (specify)

Other:

Page 12

MEDICAL HISTORY (Continued)

Major surgeries - Please describe and give dates:

SURGERY DATE(S) RESULTS

Major injuries - Please describe and give dates: INJURY DATE(S) RESULTS

Illnesses - Please list appropriate dates and any complications:

ILLNESS DATE(S) COMPLICATIONS

Ear infections

Sinus infections

Bronchitis

Pneumonia

Thrush

Chicken Pox

Seizures

Mono

Other: (Please list):

Page 13 Parent’s Last Name

Child’s Last Name

Medication or Supplements Please check (3) substances taken now or in the past and mark the appropriate reaction

now past Medication or Supplement

Central Nervous System

Clozaril (clozapine)

Haldol

Prolixin

Risperdal

Seroquel

Stelazine

Thorazine

Zyprexa

Clonidine

Cogentin

Deanol (deaner, DMAE)

Dextromethorphan

Lithium

Naltrexone

St. John’s Wort

Anafranil

Depakene for behavior

Depakene for seizures

Depakote for behavior

Depakote for seizures

Dilantin

Felbatol

Gabitril

Keppra

Klonopin

Lamictal

Luvox

Mysoline

Very Good None Bad Good

Very Bad Comments

Bad then Good

Page 14 Parent’s Last Name

Child’s Last Name

Medication or Supplements Please check (3) substances taken now or in the past and mark the appropriate reaction

now past Medication or Supplement

Central Nervous System

Neurontin

Paxil

Phenobarbital

Straterra

Tegretol

Topamax

Trileptal

Valium

Zarotin

Zonegran

Adderall

Prozac

Zoloft

Amphetamine

Cylert

Dexedrine, dextroamphetamine

Fenfluramine

Focalin

Ritalin

Buspar

Chloral hydrate

Valium

Desipramine

Mallaril

Tofranil

Klonapin

Antihistamines Benadryl

Very Good None Bad Good

Very Bad Comments

Bad then Good

Page 15

Parent’s Last Name

Medication or Supplements Please check (3) substances taken now or in the past and mark the appropriate reaction

now past Medication or Supplement

Claritin

Singulair

Zyrtec

Digestive Flora

Antibiotics (specify type and num- ber of times)

Bactrim (septra)

Diflucan

Humatin

Lamisil

Nizoral

Nystatin

Saccharomyces boulardii

Sporonax

Transfer Factor (oral)/ Colostrum

Yodoxin

Digestion Bethenecol

Digestive enzymes

Pepsid

Peptidase enzymes

Probiotics

Detoxification DMPS

DMSA (succimer, chemet)

Reduced glutathione (TTFD)

Reduced glutathione (IV)

Reduced glutathione (oral)

Folic Acid

Melatonin

Very Good None Bad Good

Very Bad Comments

Bad then Good

Page 16

Medication or Supplements Please check (3) substances taken now or in the past and mark the appropriate reaction

now past Medication or Supplement Very Good

Nutrition and Metabolism Multivitamin (Specifiy)

Vitamin A

Vitamin C

Vitamin B3 (Niacin)

Vitamin B6

5 HTP

Alpha Keto Glutarate (AKG)

Amino Acid Mix

Deanol

Dimethylglycine (DMG)

GABA

Glutamine

SAMe (SAM, Samyr)

TMG

Taurine

Tryptophan

Tyrosine

Calcium

Magnesium

Manganese

Selenium

Zinc

Human Growth Factor

IV Immune globulin

Kutapressin

Good None Bad Very Bad

Bad Comments

then Good

. Page 17

Medication or Supplements Please check (3) substances taken now or in the past and mark the appropriate reaction

now past Medication or Supplement

Nutrition/Metabolism (cont.) Oral Immune globulin

Secretin (IV)

Secretin (transdermal/sublingual)

Steroids (oral)

Steroids (topical)

DHA rich oils

EPA rich oils

Omega 6 rich oils

Cod liver oil

Flax oil

Other Activated Charcoal

Alka Gold

Carbatrol

Tranxene

Famvir

Valtrex

Zovirax

OTHER:

Very Good None Bad Good

Very Bad Comments

Bad then Good

Page 18

Therapies and Diets Please indicate therapies and diets you have used and/or are using.

now past Very Good None Bad Very Bad

now past

Therapies

Acupuncture Auditory Training

Craniosacral

Energy Therapy (Specify)

Homeopathy

Lovaas (ABA)

Naturopathy

Neural Therapy

Occupational Therapy

Osteopathy

Physical Therapy

Sensory Diet

Speech Therapy

Other:

Diets

Gluten Free

Casein Free

Yeast Free

High Protein/ Low Carb

Salicylate Free

Low Phenolics

IgG reactive food avoidance

Specific Carbohydrate Diet

Other:

Good Bad

Very Good None Bad Very Good Bad

Comments then Good

Bad Comments

then Good

Page 19

SIGNS AND SYMPTOMS Please check (3) any signs/symptoms your child may demonstrate and note duration

and details if appropriate: No. Description

1 Stimming (repetitive actions or movements)

2 Rocking

3 Head banging

4 Self-mutilation

5 Nail biting

6 Hand/arm biting

7 Nail/skin picking

8 Aggressiveness (hitting, kicking, biting others)

9 Mood swings

10 Irritability/tantrums

11 Fears/anxieties

12 Hyperactivity

13 Inability to concentrate/focus

14 Always fidgety in his/her seat

15 Impulsive

16 Breath holding

17 Dizziness

18 Seizures

19 Poor coordination

20 Problems with buttons, ties, snaps or zippers

21 Processing problems - visual, motor, language, etc.

22 Problems with social interactions

23 Sensitive to crowds

24 Trouble remembering

25 Low self-esteem

26 Fatigue

27 Cold hands/feet

28 Cold intolerance

29 Heat intolerance

Mild Moderate Severe Duration Unique details

Page 20

SIGNS AND SYMPTOMS (Continued) Please check (3) any signs/symptoms your child may demonstrate and note duration

and details if appropriate: No. Description Mild Moderate Severe 30 Recurrent/chronic fever

31 Flushing

32 Difficulty falling to sleep

33 Night waking

34 Nightmares

35 Difficulty waking

36 Bed wetting/soiling

37 Day time wetting/soiling

38 Numbness/tingling in hands/feet

39 Headache

40 Blinking

41 Tics

41 Eye discharge

43 Dark circles/puffiness under eyes

44 Night-blindness in child/family

45 Congestion

46 Dripping nose

47 Sensitivity to bright lights

48 Earaches

49 Ringing in ears

50 Sensitive to sounds/noise

51 Bad breath

52 Nose bleeds

53 Acute sense of smell

54 Sore throats

55 Hoarseness

56 Cough

57 Wheezing

58 Geographic tongue

59 Swollen gums

Duration Unique details

Page 21

SIGNS AND SYMPTOMS (Continued) Please check (3) any signs symptoms your child may demonstrate and note duration

and details if appropriate: No. Description Mild Moderate Severe 60 Canker sores

61 Dry lips/mouth

62 Diarrhea

63 Constipation

64 Bloating

65 Passing gas

66 Belching

67 Stomach ache

68 Refusal to eat

69 Sensitive to texture of food

70 Difficulty swallowing

71 Food Craving

72 Grinding teeth

73 Mucous/blood in stools

74 Anal itching

75 Calf cramps

76 Other muscle cramps/spasms

77 Tremors

78 Weakness

79 Stiffness

80 Eczema

81 Psoriasis

82 Hives

83 Acne

84 Seborrhea (cradle cap)

85 Other rashes

86 Easy bruising

87 Itchy scalp

88 Dry skin

89 Oily skin

90 Pale skin

Duration Unique details

Page 22

SIGNS AND SYMPTOMS (Continued) No. Description Mild Moderate Severe Duration Unique Details 91 Sensitivity to insect bites

92 Sensitive to texture of clothes

93 Cracking/peeling hands

94 Cracking/peeling feet

95 Strong body odor

96 Strong urine odor

97 Strong stool odor

98 Soft nails

99 Thickening of nails

100 Ridges/pitting of nails

101 White spots/lines on nails

102 Brittle nails

103 Any OCD (obsessive com- pulsive) behaviors

104 Strategies to put pressure On abdomen

105 Reflux

106 Persistent colic

107 Toe walking

23

SIGNS AND SYMPTOMS (Continued)

Describe any other symptoms you would like me to know about your child:

List any other history, pertinent thoughts or questions that you want to address:

Vaccine Record or attach a copy/date and any reaction

Diphtheria/Pertussis/Tetanus Date Bowel Swelling Crying Seizure Irritable Fever OtherDTaP1DTaP2DTaP3DTaP4DTaP5AdultDiphtheria/Tetanus(TD)PediatricDiphtheria/TetanusHInfluenzaTypeB Date Bowel Swelling Crying Seizure Irritable Fever OtherHIB1HIB2HIB3Polio(circleoralorInjection.)Date Bowel Swelling Crying Seizure Irritable Fever OtherOPV1/Injection1OPV2/Injection2OPV3/Injection3OPV4/Injection4Measles/Mumps/Rubella Date Bowel Swelling Crying Seizure Irritable Fever OtherMMR1MMR2HepatitisBVaccine Date Bowel Swelling Crying Seizure Irritable Fever OtherHBV1HBV2HBV3Prevnar13(orother) Date Bowel Swelling Crying Seizure Irritable Fever Other1dose2dose3dose4doseRotovirus Date Bowel Swelling Crying Seizure Irritable Fever Other1dose2dose3doseHepatitisA Date Bowel Swelling Crying Seizure Irritable Fever Other1dose2doseMiscellaneous Date Bowel Swelling Crying Seizure Irritable Fever OtherVaricella(ChickenPox)1Varicella(ChickenPox)2FluVaccine1FluVaccine2FluVaccine3FluVaccine4FluVaccine5Other

Helpfulresources

BooksHealingandPreventingAutism,byJennyMcCarthyandJerryKartzinel,MDHealingtheNewChildhoodEpidemics:Autism,ADHD,Asthma,Allergies,byKennethBockMDVaccines,Autism&ChronicInflammation:TheNewEpidemic.BarbaraLoeFisher(NVIC.org)SpecialDietsforSpecialKidsandSpecialDietsforSpecialKidsTwo,byLisaLewis

WebsitesAutismResearchInstitute(www.autism.com/ari)TalkAboutCuringAutism(www.tacanow.org)CenterfortheStudyofAutism(www.autism.org)AutismOne(www.autismone.com)AutismNetworkforDietaryIntervention(www.autismndi.com)DevelopmentalDelayResources(www.devdelay.org)GenerationRescue(www.generationrescue.org)

Gluten-Free/Casein-FreeDiets/CeliacDisease/GlutenIntolerancewww.circleoflifenutrition.netMarjie’sGlutenFreePantry(locatedindowntownFenton)Therecipediva(www.therecipediva.com)http://www.thecandidadiet.com/gluten-allergies-healthy-diet.htmCeliacSprueAssociation(www.csaceliacs.org)GlutenIntoleranceGroupofNorthAmerica(www.gluten.net)CeliacDiseaseFoundation(www.celiac.org)GlutenFree/CaseinFreeDiet(www.gfcfdiet.com)Gluten-Freelinks(/www.gflinks.com)KinnikinnickFoods(www.kinnikinnick.com)Pamela’sProducts(www.pamelasproducts.com)TheAllergyGrocer(www.allergygrocer.com)TheGlutenFreeMall(www.glutenfreemall.com)TheGlutenFreePantry(www.glutenfree.com)ShelleyCase,RD(authorof“GlutenFreeDiet)(www.glutenfreediet.ca)QuickStartDietGuide(www.enjoylifefoods.com)www.glutenfreeliving.com(magazine)www.livingwithout.com(magazine)www.glutenfreecookingclub.comwww.glutenfreedrugs.com(forprescriptionandOTCdrugs)

EnvironmentalHealthInstituteforChildren’sEnvironmentalHealth(www.iceh.org)Children’sHealthEnvironmentalCoalition(www.checnet.org)TheGreenGuide(www.thegreenguide.com)EnvironmentalWorkingGroup(www.ewg.org)TheCollaborativeonHealthandtheEnvironment(www.healthandenvironment.org)