[AVN] Autism Research Institute - Secretin Outcome Survey (SOS) Form

[Guest guest]

From: " Holly Bortfeld " <bordman@...>

Autism Research Institute - Secretin Outcome Survey (SOS) Form

Please Fill in on-line and email to SOSFORMS@.... As some of you may

recall, Dr Rimland stated that they had only received about 200 SOS forms

and

many of them were illegible from faxing. ARI has given us permission to

create this email form. You can simply fill it out online and email it to

SOSFORMS@.... We are all looking for answers and trends and together

we

can all help to discover these. Please, please fill this out ASAP. We

will

all benefit! If you have questions, please direct them to

SOSFORMS@....

Thank You!

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Today's Date:

Patient:

Physician:

Diagnosis (put X in front of one or more):

___ Autism ___ Asperger ___ PDD ____ Other ________________________

Patient Age Now: Yrs Mos Age of Onset:

Sex: Weight (indicate lbs or kgs):

Patient's General Pre-Secretin Functional Level (put X in front of one):

_____ High _____ Medium _____ Low

*Provide details if needed (eg/ speech=Low, Interaction=High, etc)

Do you have any ideas/clues about the cause of the patient's problem?

___ No Idea __ Yeast __ Vaccination __ Diet/Digestive Disorder

___

___ Antibiotics ___Other ______________

Does the patient have any other associated problems (eg/seizures)?

Describe:

Pre-Secretin Bowel/Digestive Problems and Severity:

Constipation: _____No problem ____Mild ____ Moderate ____Severe

Corrected by Secretin? ____Yes ---> How long:

____No -----> Worse?: ___Y ___N How

long:

Diarrhea: _____No problem ____Mild ____ Moderate ____Severe

Corrected by Secretin? ____Yes ---> How long:

____No -----> Worse?: ___Y ___N How

long:

Post-Secretin

Increase in Urination: ____Yes* ____No

*(if yes) When: Days ____ thru _____

Changes which seem Secretin-Related

Please enter the date that secretin was given under 1st Date, 2nd Date,

etc...

.. After the Date, please rate the change that that secretin infusion

brought

about with *. Put 4 aserisks (**** ) for greatest change, 3 asterisks

(***)

for next greatest change, and so on down to 1 (*) for least change (if

there

are fewer than 4 infusions, just start at 4 *s and go down).

Under each date that secretin was given, please tell us about the changes

that

you noticed and when they were in effect. Use the ratings below. There is

a

space at the end of the form for additional information not captured in

this

area.

Change: Rate -1 to 4 where -1=worse, 0=no change, 1=possible

2=moderate,

3=significant,

4=great

Duration: Change seen between days _____thru _____. Day 0=1st day

You can also put eg/ " wks 2 thru 4 " . If you haven't

kept

close

track, just type over this area and put your best guess.

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1st Date 2nd Date 3rd Date

4th Date

_________ _________ _________

_________

Dose : _________ _________ _________

_________

Eye Contact:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Socialization (better play, greetings, imitation):

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Attention (easier to teach):

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Compliance:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Mood (less crying, tantrums) *This section is for general Mood after

infusion.

If you saw temporary worsening right after secretin, please fill out the

next

" First Days Mood " section.

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

*First Days Mood (fill out if you saw a change in the days following

secretin

administration that subsided/changed after a few days):

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Hyperactivity:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Anxiety, compulsions:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Stimming:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Comprehension/Understanding:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Speech/Language:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Sound Sensitivity:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Digestion (Diarrhea, Constipation):

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Sleep:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Vision:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Other (please name) _________________:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Appetite:

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Weight Gain? Please put gain under each date (indicate lbs/kgs). If none,

put

" 0 " .

change: _________ _________ _________

_________

(Adverse) Side Effects (known/suspected):

change: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Any New Positive Skills or Behaviors?

description: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Was patient on any medications/supplements/other therapies at time of

secretin

administration or period of secretin effectiveness? (please copy this area

and

add more if applicable)

Med/Supp: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Med/Supp: _________ _________ _________

_________

duration: ___ thru __ ___ thru __ ___ thru __

___

thru __

Do you think that any of the above changed the effectiveness of the

secretin?

If so, how?

Patient fasting before secretin? Enter # of hours under each date, or 0 if

not.

_________ _________ _________

_________

Was patient doing any special diet? Describe.

Any other therapies being used? Describe.

Have you tried any other methods of secretin administration (eg/

sublingual,

transdermal)? Why (eg/IV unavailable, etc)? Which Method? Frequency?

Results? Add any other details that you would like us to know.

Please add any other information that you would like us to know.

Thank You! Please return to: SOSForms@...

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