Parent Survey - Efficacy of Hyperbaric Oxygen Treatment (HBOT)

4.) Current age of child:
Years 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20-29 years 30-39 years 40-49 years 50-59 years 60 or older Months 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months

5.) Date of birth (format: mo/da/yr):

6.) Sex: Male Female

7.) Diagnosis: You may check more than one diagnosis.

Autism Asperger Syndrome PDD-NOS Landau-Kleffner Syndrome
Fragile X Syndrome Retts Syndrome Not yet diagnosed
Other (please specify):

8.) Level of Functioning: Low Moderate High

9.) Did autism start after a period of normal development? Yes No
If 'yes,' at what age (months):

10.) I have not yet started HBOT, so I cannot complete the rest of the survey. Please send me your findings as they become available.

11.) Has your child receive chelation treatment before, during or after receiving HBOT?

He/she received chelation treatment before HBOT.

Please rate the effectiveness of the chelation treatment: Definitely Helped Moderate Improvement Possibly Helped No Definite Effect Made a Little Worse Made Much Worse

He/she received chelation treatment after HBOT.


Please rate the effectiveness of the chelation treatment: Definitely Helped Moderate Improvement Possibly Helped No Definite Effect Made a Little Worse Made Much Worse

He/she received chelation treatment during HBOT.


Please rate the effectiveness of the chelation treatment: Definitely Helped Moderate Improvement Possibly Helped No Definite Effect Made a Little Worse Made Much Worse

He/she has not received chelation treatment.


Please rate the effectiveness of the chelation treatment: Definitely Helped Moderate Improvement Possibly Helped No Definite Effect Made a Little Worse Made Much Worse

12.) Do you own an HBOT chamber, or did/does your child receive HBOT at a clinic?

Yes, we own an HBOT soft chamber.

Yes, we own an HBOT hard chamber.

My child uses an HBOT soft chamber at a clinic. (Which clinic? )


My child uses an HBOT hard chamber at a clinic. (Which clinic? )

12a.) If your child received HBOT at a clinic, what was the cost of each session?

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13.) Please provide the details of the HBOT treatment of your child. Don't worry if you cannot answer every question listed below. If you can, please indicate the percentage of oxygen given, treatment schedule, total number of treatments, and amount of pressure treated, and, most importantly, its effectiveness. (If your child has had more than one series of HBOT, use this space to report on the first series, and Question 13B to report on the second series.)

- A -

PLEASE SELECT A LETTER TO RATE EACH OF THE SYMPTOMS / BEHAVIORS THAT YOU BELIEVE HAVE CHANGED AS A RESULT OF HBOT:

- B - If your son/daughter received more than one series of HBOT treatments, either using the same chamber or two different chambers, please complete the form below, for the second series.

PLEASE SELECT A LETTER TO RATE EACH OF THE SYMPTOMS / BEHAVIORS THAT YOU BELIEVE HAVE CHANGED AS A RESULT OF THE SECOND SERIES OF HBOT:

14.) If your son/daughter was treated in more than one type of chamber, based on your experience, which one would you recommend to other parents? (Please include type of chamber, pressure, and percent oxygen, if known.)

15.) Important! Please add any additional information, comments or observations that might be helpful. For example, if a SPECT scan was performed on your child before and after HBOT, what were the results?

16.) If we have further questions, may we contact you?