AUTISTIC CHILDREN STUDY

MELISA^TM TESTING QUESTIONNAIRE

Dr. Deborah Baker, D.C., MSc. (Nutrition/Biochem), D.I.Hom.

ãMELISA MEDICA FOUNDATION

Date:.........................

Name of Child:.......................................................................................

Date of Birth:.............................

APGAR score at birth:................................

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Date of Diagnosis of Autism:.............................................................……………..

Name of Parents:...................................................................................................

Date of Birth of Parents: M........................................F.......................................…

Address:..............................................................................................................…

Telephone: (Res.)...............................................Bus..........................................…

E-mail address:..................................................................................................…...

Parents profession:

Mother: A: Prior and during pregnancy……………………………….

B, Current profession………………………………………….

Father: A, Prior and during pregnancy………………………………..

B, Current profession………………………………………….

1.Child’s health

Developmental Landmarks (Age):

Crawling.............................................Delayed in your opinion…………………….

Sitting.................................................Delayed in your opinion?.........................

Walking..............................................Delayed in your opinion?.........................

Talking...............................................Delayed in your opinion?.........................

What symptoms of Autism/delayed development does your child have?................

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Vaccination history of your child:

Name of the vaccine Manufacturer Date

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Did any of the previous landmarks change post-vaccination?.................................

If so, what changed and how long after vaccination?..............................................

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Did you observe any other side-effects of vaccination such as fever, tiredness, local

reactions or others?…………………………………………………………………………

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If there were post-vaccine side-effects, how long did they last?……………………..

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Please list all laboratory testing done, particularly for mercury and other metals:

Test Date Results

Was any testing done with the help of DMSA or DMPS ?

If yes, when?

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If provocation test was used, did you observe any changes in child’s health/behavior directly or during the days after provocation testing?

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Does your child suffer from any respiratory/breathing problems?........................

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Medications?........................................................................................................................

Does your child suffer from digestive problems such as gas, bloating, “tummy aches”, cramping, chronic diarrhea, constipation, food sensitivities?

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Are those problems appearing always in connection with certain foods?

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Medications?............................................................................................................

Does your child have skin lesions/eczema/rashes of any kind?..............................

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Medications?................................................................................................................

Is your child’s skin irritated by metal fasteners (jeans), costume jewelry, etc?...

Is your child wearing metal earrings?…………………………………………………….

Does your child experiences any discomfort in connection with metal earrings?

If yes, when?

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Was your child bearing metallic braces?

If yes, when and for how long?……………………………………………………………

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Does your child have any silver/mercury dental fillings?.........................................

If yes, how many?.....................................................................................................

When were they placed?

Date Where in the mouth?

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Was your child breastfed? If yes, for how long?......................................................

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Is your child taking any nutrition supplements?

If yes, which ones and for how long?

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2.Maternal Health

Do you experience problems with cosmetics or make up?

If yes, which ones?………………………………………………………………………….

Do you have pierced ears?……………………………………………………………….

If yes, do you wear earrings?……………………………………………………………..

Do you tolerate metallic earrings?………………………………………………………..

If no, which ones?………………………………………………………………………….

Are you aware of any allergy to penicillin or sulfa drugs?…………………………

Do you suffer from food allergies?………………………………………………………

Do you have allergies to house dust mite or animal dander?……………………………

……………………………………………………………………………………………………

Do you suffer from any autoimmune or chronic degenerative

diseases?……………………….…………………………………………………………………

….………………………………………………………………………………………………….

Do you have silver/mercury fillings?....................................................................

If yes, how many?.................................................................................................

Did you have the mercury fillings during your child’s pregnancy?...............................

Did you have dental work during the pregnancy?………………………………………..

If yes, what kind?........……………………………………………………………………….

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Do you have other metals or root canals in your mouth?

If yes, please indicate(X) materials and time period

A: Before B: During C: During

pregnancy pregnancy breast feeding

Golden crowns

and bridges………………………………………………………………………………………

Titanium crowns………………………………………………………………………………….

Metal-based ceramics…………………………………………………………………………….

Nickel-containing

alloys…………………………………………………………………………………

Root canals............................................................................................................................

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Did you have any vaccinations during pregnancy?..............................................

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Did you have any vaccinations

during breast feeding?....................................................................................................

Please list any:

Date Vaccination Manufacturer

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Did you receive Rhogam injections? (for RH negative mothers)........................

Date:................................................................................................................

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Do you or did you in pregnancy/breastfeeding use eye/nose drops?.................

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3.Environmental exposure

and genetic factors

Do you and your family live near a factory, industry, coal smelter, crematorium,

highway or airport?..........................................................................................

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Do any siblings of this child have autism/ADD/PDD or any learning disabilities?

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Are there any allergies or autoimmune diseases in the family………….

A: Mother’s side of family………………………………………………………………

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B: Father’s side of family (including father)

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Parental smoking habits:

Mother: A: Did you smoke prior and during pregnancy……………………

B: Do you smoke now?…………………………………………….

C: Are you passive smoker? If yes, when?………………………

Father: A: Did you smoke prior or during pregnancy?……………………

B: Do you smoke now?……………………………………………

C: Are you passive smoker? If yes, when?……………………

Thank you,

Dr. Deb Baker

Dr. Vera Stejskal