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