Database Collection DEMOGRAPHIC STUDY

ASCENSION AUTISM and GUT HEALTH CONSULTING

data collection Marguerite O Reilly
These questions can be modified based on the specific needs of the study and the population being studied.
1. Has your child been diagnosed with autism or any other developmental disorder?

YesNoNot sureNAWaiting on StatementOther
2. Has your child been diagnosed with a mitochondrial disorder?

AttendeeYesNoNot Sure
Please state their or your conditions i.e ADHD
.3. Does your child have any dietary restrictions or preferences?

YesNonot sureOther
4. Does your child take any medications or supplements?

YesNoNot SureSometimesSupplementsNHS
5. Has your child been exposed to any environmental toxins or pollutants?

YesNoNot SureOther
6. Has your child had any recent illnesses or infections? .

YesNoNot SureOther
7. Has anyone in your family been diagnosed with autism or a mitochondrial disorder?

YesNoMaybeOther

8. Has anyone in your family had any gastrointestinal issues?

9. Please state your home county . tick the box please .

ACKNOWLEDGMENT
** This form must be fully completed and signed before informtion can be entered into our Referral Database. *
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ASCENSION AUTISM and GUT HEALTH CONSULTING