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Let's Get Down to the Basics!
Are you the childs mother or father?
Mother
Father
Child's Info
Let's get your child's vitals.
Date of Birth:
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Weight
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Male
Female
Any official diagnosis?
Select all that apply.
Autism Spectrum Disorder
PANDAS/PANS
ADHD
Hyperlexia
Global Development Delay
Sensory Processing Disorder
Expressive Language Disorder
Cerebral Palsy
Other
None
Child's Symptoms
Help us understand your child. Please select the symptoms that apply.
Sensory/Cognitive
Speech/Language
Social
Doesn't respond to name
Doesn't respond to "no"
Doesn't follow commands
Doesn't speak at all
Apraxia
Echolalia
Scripting
Obsessive speech
Receptive issues
No expressive speech
No functional speech
No conversational speech
Never babbled
No use of gestures
Reverses pronouns
No eye contact
Uncooperative
Zones out
Prefers to be alone
Shows no affection
Doesn't greet people
Avoids contact
Does not share
Doesn't like hugging
Does not imitate
Does not wave 'bye'
Doesn't smile
Can't focus
Misses social cues
Runs away
Doesn't respond to name
Doesn't respond to praise
Doesn't look at people
Doesn't draw/color
Inappropriate toy play
Doesn't understand stories
Unaware of danger
Unaware of environment
No imagination
Doesn't initiate activities
Can't dress self
Toe walking
Bad balance
Spins objects
Bed-wetting
Wets pants/diapers
Diarrhea
Constipation
Sleep problems
Eats too much
Doesn't eat enough
Extremely limited diet
Hyperactive
Lethargic
Injures Self
Hits others
Sound sensitive
Anxious
Tantrums
Seizures
Obsessive Speech
Rigid Routines
Hand Flapping
Demand sameness
Often agitated
Have you tried any biomedical treatments?
Please select which ones below
Andy Cutler Chelation
Nemechek Protocol
Stem Cell Therapy
Biofilm Protocol
Ionic Footbath
Homeopathy
Antiviral Protocol
Methyl-B12 Shots
Yasko's Protocol
Infrared Sauna Therapy
Other
None
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