Autism Questionnaire

Autism Questionnaire + Diet- feedback from parents

  • MM slash DD slash YYYY
  • 1. Bowel function - stool characteristics (please give one answer for each of the following)

  • 2. Please state any changes in the diet or supplementation of your child.

  • 3. Has your child started on any new medication or therapy?

  • 4. Does your child sleep well at night time?

  • 5. Please rate your child’s behaviour and digestive symptoms using the scale below which ranges from 0-9

    0 never shows this particular symptom or behaviour; 1 or 2 slight/unobtrusive; 3 or 4 mild; 5 or 6 moderate; 7 or 8 severe; 9 extreme/incapacitating
  • 6. Please share, on the paragraph below, any extra information that you think might be important at this stage.

  • Please write below your child's diet diary in a giving week

  • Max. file size: 512 MB.