Secretin Outcomes Survey Form
Autism Research InstituteSECRETIN OUTCOMES SURVEY (S.O.S.) FORM
TO BE COMPLETED BY PARENTS OF CHILDREN GIVEN SECRETIN
AND RETURNED TO ARI THREE WEEKS AFTER EACH INFUSION
Patient______________________Physician__________________ Today's Date____________
Diagnosis (circle one or more): Autism Asperger PDD Other____________
Patient age_____ Age of onset_____ Sex____ Weight_______(indicate lbs. or kg.)
Child's pre-secretin functional level (circle): High Medium Low
Circle any pre-secretin bowel/digestive problems, and severity:
Not a Corrected by
Constipation: Problem Mild Moderate Severe secretin? __yes __temp. __no
Not a Corrected by
Diarrhea: Problem Mild Moderate Severe secretin? __yes __temp. __no
Dose of secretin given for each infusion, if known___________________________
Date(s) secretin was given: ___________ ___________ ___________ __________
(Approx. dates okay. Please use a double asterisk (**) to note the date secretin
was given that brought the greatest change, and use a single asterisk (*)to note
the date of second greatest change, if more than one dose given.)
____________________
| In column A, | IMPROVEMENTS WHICH SEEM SECRETIN-RELATED
| rate improvement | A. B. C.
|n/a=not applicable| Improvement Days between Comments
| 0=none | Rating(0-4) secretin and
| 1=possible | Use -1 to improvement.
| 2=moderate | indicate a Use '0' to
| 3=significant | worsening indicate change
| 4=great | of behavior. in same day.
Eye contact..........__________ ____________ ___________________________
Socialization........__________ ____________ ___________________________
(better play, greetings, imitation)
Attention............__________ ____________ ___________________________
(easier to teach)
Mood.................__________ ____________ ___________________________
(less crying, tantrums)
Hyperactivity........__________ ____________ ___________________________
Anxiety,compulsions..__________ ____________ ___________________________
Stimming.............__________ ____________ ___________________________
Comprehension/ ......__________ ____________ ___________________________
understanding
Speech/language......__________ ____________ ___________________________
Sound sensitivity....__________ ____________ ___________________________
Digestion............__________ ____________ ___________________________
(diarrhea, constipation)
Sleep................__________ ____________ ___________________________
Other................__________ ____________ ___________________________
Any new positive behaviors or skills? __________________________________________
Any side (adverse) effects (known or suspected)? __________________________________
Do you have any ideas/clues about the cause of your child's problem?
___no idea ___yeast ___vaccination ___diet ___other_______________________
What other therapies are being used?__________________________________________________
Autism Research Institute, 4182 Adams Avenue, San Diego, CA 92116. FAX: 619-563-6840
If you would like a copy of the results of this parent survey, please write name, address, phone, fax below
___________________________________________________________________
Thank you for your help!
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