Database Collection to help other famlies understand the Gut

ASCENSION AUTISM and GUT HEALTH CONSULTING

data collection Marguerite O Reilly 13Nov 2023
Please state , does your child or yourself have a statement?

YesNoNot sureLive outside ukNAOther
How many children do you have with autism or do you have any health issues yourself or in your family?
In the UK, it is necessary to provide a statement confirming your child's autism diagnosis prior to making any medical or educational arrangements.
Please tick how many children you have with autism or if its you just tick box parent or attendee

1234567890parentAttendee
Please state their or your conditions i.e ADHD
Please complete a separate form for each child, if possible. Since each child may experience different symptoms, we aim to create an individual profile for each child to ensure their future well-being. We would greatly appreciate it if parents could also provide information about any solutions they have tried from our Protocol, as this will help us gain a better understanding of the child's gut health.
Have you heard of our Protocol on FaceBook ? please state if different .

YesNonot sureGoogleWebsiteWord of MouthInstagramYoutudeUSANorthern Ireland
Did you get reduced symptoms from our Protocol

YesNoNot sureHave not tried yetWe couldn't do the protocol every day.
Please tick overall performance for reduced symptoms

10 %20%30 %40 %50%60 %70%80%90%100%0%
Please state your childs symptoms before the protocol

SensoryAnixityArm FlappingOCDStimmsHummingspinningnon verbalreapative talkingBowel ProblemsSmearingMotor FunctionsMuslce Spamspoor cordintionbehaviopur issuesViolenceFearfulMorbidSuicidalCuttingOther
Please describe any symptoms that have improved after following the protocol for your child.

SensoryAnixityArm FlappingOCDStimmsHummingspinningnon verbalreapative talkingBowel ProblemsSmearingMotor FunctionsMuslce SpamsPoor cordintionBehaviopur issuesViolenceFearfulMorbidSuicidalCuttingOther
Please tick symptoms that improved after being on the protocol for less than 3 months."

SensoryAnixityArm FlappingOCDStimmsHummingspinningnon verbalreapative talkingBowel ProblemsSmearingMotor FunctionsMuslce SpamsPoor cordintionBehaviopur issuesViolenceFearfulMorbidSucidalCuttingDid not mange Protocol everydayNAOther
Please tick symptoms improved 3 to 6 months

SensoryAnixityArm FlappingOCDStimmsHummingspinningnon verbalreapative talkingBowel ProblemsSmearingMotor FunctionsMuslce SpamsPoor CordaintionBehaviopur issuesVolinceFearfulMorbidSucidalCuttingDidnt mange doing protocol everydayNAOther
Which symptoms can be controlled by feeding the microbiome daily while following your protocol for 1 to 4 and a half years?"

SensoryAnixityArm FlappingOCDStimmsHummingspinningnon verbalreapative talkingBowel ProblemsSmearingMotor FunctionsMuslce SpamsPoor cordiantionbehaviopur issuesViolenceFearfulMorbidSucidalCuttingDid not mange protocol everydayNAOther

Please state the Solutions you used from the Protocol

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied	Excellent	Not used
VITIMIN C
VITIMIN D
MAGNESIUM
SILICA WATER
ORANGIC SULPHER
SEA KELP
PROIBOTICS

PLEASE RATE CAN YOU RATE OVERALL VIEW OF OUR PROTOCOL , COMPARED TO OTHERS YOU HAVE TRIED BEFORE OR YOUR LOCAL HEALTHCARE PLAN TO REDUCE SYMPTOMS

	1	2	3	4	5

1 is Worst, 5 is Best

ACKNOWLEDGMENT
** This form must be fully completed and signed before informtion can be entered into our Referral Database. *
Should be Empty:

ASCENSION AUTISM and GUT HEALTH CONSULTING

ACKNOWLEDGMENT