Response-O-Matic Form

 

Problem Report Form

In order to be able to provide help, ALL questions must be answered.



This form is for problems that cannot be resolved by reading BTVC or the Pecanbread.com website.

 

Your name:

Child's name:

Email address:

Briefly describe problem you are reporting.

 

Child's Diagnosis

(Check all that apply.)

ASD
ADD
Celiac
Crohn's Disease
Ulcerative Colitis
Seizures
None of these

 

Any seizures prior to SCD™?

Yes
No

 

Length of time on SCD™ 100%

Less than one week
One week
Two weeks
Three weeks
Four weeks
Five weeks
Six weeks
Seven weeks
Eight weeks
Three months
Four months
Five months
Six months
More than six months

 

Any improvements on SCD™?

Digestion:

Yes
No

Behavioral:

Yes
No

Language:

Yes
No

Attention:

Yes
No

Cognitive

Yes
No

 

Type of Probiotic Used

Custom Probiotics
Nature's Life
Other SCD™ Legal Brand
Other Illegal Brand

 

Total amount of probiotics used daily:

Less than 1 Billion Cells
1 Billion Cells
2 Billion Cells
3 Billion Cells
More than 3 Billion Cells

 

How many times daily are probotics being given?

Once
Twice
Three times
Four or more times

 

What type of yogurt is being used?

Goat
Cow
Nut milk
None

 

What type of yogurt starter is being used?

Lyosan
Lyosan, 2nd Generation
PA Goat Yogurt
Custom Probiotics Starter
Other

 

What enzymes are being used?

(Check all types used.)

Digest Gold
Ultra-Zyme
Vitase
EnZymAid
Enzym-Complete/DPP IV
Multi-Enzyme Formula
Peptidase Complete
Other legal enzyme brand
Houston Enzymes (illegal)
Other illegal enzyme brand

Is the child following a chelation protocol?

Yes
No

Which protocol?

DAN! / 8 hour DMSA
DAN! / 8 hour DMSA/ALA
Andy Cutler protocol
TTFD
TTFD and DMSA
TTFD and DMSA/ALA
Other protocol

 

Have you checked the legality of every food you give your child?

Breaking the Vicious Cycle

Yes
No

 

Type of nut flour or nut butter used:

(Check all types used.)

Almond
Cashew
Filbert (Hazelnut)
Pecan
Walnut
Other

 

Daily amount of nuts used:

Less than 1/4 cup
1/4 cup
1/2 cup
3/4 cup
1 cup
More than 1 cup

 

List manufactured foods your child eats, including brand name.

 

List fruits your child eats, including preparation method.

 

List vegetables your child eats, including preparation method.

 

List meats your child eats, including preparation method.

 

Has child sneaked an illegal food?

Yes
No

 

How often?
Once
Once per week
Once per day
More than once per day

 

Does the child attend school?

Yes
No

 

Is there an opportunity for infractions?

Yes
No

 

Do you have illegal food in the house that child might access?

Yes
No

 

Does your child take supplements?

Yes
No

 

Have you checked to see if all supplements are legal?

Supplements List

Yes
No