Mercury Detoxification Evaluation Form

We are very interested in receiving comments and observations from parents of autistic children on the effects of the mercury detoxification process. Please complete this form just before the child is started on the detoxification program. Complete follow-up reports monthly during the treatment. Findings will be reported on our web site and in the Autism Research Review. If you would like a hard copy of the evaluation form, click here to download an Adobe Acrobat file (pdf). You may track your child's improvement by entering the report every month on this web site, which will immediately give you your child's score.

Today's Date [use format: mo/da/yr]:

Child's Name (first, last):
/

Address1:
Address2:
City: , State: Zipcode/Postal code:
Country [if outside U.S.]:

Telephone: Fax:
E-mail: <==Please enter your e-mail address

Form Completed By: [first and last name]
Relationship: [e.g., mother, teacher]

Date of Birth [format: mo/da/yr; e.g., 09/25/98]:

Age:

Sex of Child: Boy Girl

Functioning Level: Low Medium High

Age of Onset (months):

Do you believe his/her autism was caused by a vaccine? Yes No Maybe

If so, which?

Number of Detox Treatments: Date Detox Started:

Name of physician treating child:
City/State:

If your child has not yet begun a mercury detoxification procedure, please complete only section A. For 30-day follow-up reports, please complete sections A and B.

Section A -- Current Status

Click the appropriate value

	No Problem	Mild Problem	Mod. Problem	Severe Problem
Aggression
Agitation/Irritability
Awkward body movements
Constipation
Diarrhea
Eating/feeding problems
Inappropriate use of toys
Irrational fears
Lack of awareness
Lacks eye contact
Lacks speech
Obsessive/OCB behaviors
Poor attention
Poor finger/hand skills
Repetitive, self-stim behaviors
Seizures
Self-injury
Sleep disturbances
Social deficits/withdrawal
Sound sensitivity
Speech/language deficits
Temper tantrums

Section B -- Detox Effects

Select a value on the scales below to indicate detox effects. Please base your ratings on changes observed since the detox procedure was initiated

		Made Worse		No Effect		Possibly Helped		Helped a Little		Helped a Lot		Greatly Improved
Aggression
Agitation/Irritability
Awkward body movements
Constipation
Diarrhea
Eating/feeding problems
Inappropriate use of toys
Irrational fears
Lack of awareness
Lacks eye contact
Lacks speech
Obsessive/OCB behaviors
Poor attention
Poor finger/hand skills
Repetitive, self-stim behaviors
Seizures
Self-injury
Sleep disturbances
Social deficits/withdrawal
Sound sensitivity
Speech/language deficits
Temper tantrums

Please use the space below to tell us more about the benefits, if any, seen in the past month and about any adverse effects, if any, seen in the past month. Other comments and observations are also welcome. [Please limit your comments to 250 characters (including spaces) or less.]