Autism Disorder Symptom Evaluation Form
 
The following symptoms of Autism Disorder are listed as being typical. This information is being collected to determine the effectiveness of the product provided to you.
   
Please evaluate each symptom using the following scale:
0= Not at all    1= Just a little    2= Somewhat    3= Very much

Name :  
Date :  
Symptoms Sun Mon Tues Wed Thu Fri Sat
Seems not to hear / No startle response

             
Unusual tolerance or sensitivity to environmental stimuli (i.e. pain, light, sound)
             
Little visual response to "new people" or other's facial expressions / feelings
             
Stares into space for long periods
             
Has no social smile
             
Lack of participation in social interaction. Has not developed friendships / prefers inanimate objects over people
             
Stiff, does not like to be held or touched
             
Actively avoids eye contact / Appears to look through people
             
Often frightened or anxious
             
Rocks / whirls self for long periods
             
Lunges, darts spins, walks on toes, flaps hands
             
Unusual attachment to inanimate objects
             
Hurts self or others, banging head, kicking biting, etc.
             
Does not follow simple commands
             
Does not respond to name when called among others
             
Uses gestures to obtain desired objects
             
Repeats phrases, sounds, words over and over. Echoes others statements or questions              
Uses very few spontaneous words / phrases to communicate
             
Severe temper tantrums or frequent mild tantrums
             
Insists demands are met immediately
             
Bowel problems (constipation / diarrhea)              
Pica (Eats dirt, chews ice, chews on hair)
             
Severe mood swings
             
Seems oblivious to surroundings (danger, etc.)
             
Learns a simple task but forgets easily
             
Strong reactions to changes in routine
             
Often feels, smells, tastes objects
             
Involved in complicated rituals (lining objects up, rearranging furniture, etc.)              
Supplement dosage, sleep, and medication  
Empower daily dosage (# of capsules)              
Hours of sleep              
Drug 1 daily dosage
Name:
              
Drug 2 daily dosage
Name:		              
Drug 3: daily dosage
Name:		              
Drug 4: daily dosage
Name:		              
Drug 5: daily dosage
Name:		              

Comments  
 
 
 
 
   
*Please send completed forms to Truehope Nutritional Support Ltd.
Ph: 1-888-TRUEHOPE (1-888-878-3467)
Fax: 1-888-752-7212
Email: sef@truehope.com
Mail: P.O. Box 888, Raymond, Alberta, Canada, T0K 2S0

Copyright © 2002 Truehope Nutritional Support Ltd.
Revised October 11, 2002