Patient______________________Physician__________________ Today's Date____________

Diagnosis (circle one or more):  Autism   Asperger   PDD   Other____________

Patient age_____   Age of onset_____   Sex____   Weight_______(indicate lbs. or kg.)

Child's pre-secretin functional level (circle):  High   Medium   Low

Circle any pre-secretin bowel/digestive problems, and severity:

              Not a                             Corrected by
Constipation: Problem  Mild  Moderate  Severe   secretin? __yes  __temp.  __no

              Not a                             Corrected by
Diarrhea:     Problem  Mild  Moderate  Severe   secretin? __yes  __temp.  __no

Dose of secretin given for each infusion, if known___________________________

Date(s) secretin was given: ___________  ___________  ___________  __________
(Approx. dates okay. Please use a double asterisk (**) to note the date secretin
was given that brought the greatest change, and use a single asterisk (*)to note
the date of second greatest change, if more than one dose given.)
____________________
| In column A,     | IMPROVEMENTS WHICH SEEM SECRETIN-RELATED 
| rate improvement |  A.           B.             C.
|n/a=not applicable|  Improvement  Days between   Comments
|  0=none          |  Rating(0-4)  secretin and     
|  1=possible      |  Use -1 to    improvement.     
|  2=moderate      |  indicate a   Use '0' to 
|  3=significant   |  worsening    indicate change 
|  4=great         |  of behavior. in same day.

Eye contact..........__________   ____________   ___________________________
Socialization........__________   ____________   ___________________________
(better play, greetings, imitation)
Attention............__________   ____________   ___________________________
(easier to teach)
Mood.................__________   ____________   ___________________________
(less crying, tantrums)
Hyperactivity........__________   ____________   ___________________________
Anxiety,compulsions..__________   ____________   ___________________________
Stimming.............__________   ____________   ___________________________
Comprehension/ ......__________   ____________   ___________________________
understanding
Speech/language......__________   ____________   ___________________________
Sound sensitivity....__________   ____________   ___________________________
Digestion............__________   ____________   ___________________________
(diarrhea, constipation)
Sleep................__________   ____________   ___________________________
Other................__________   ____________   ___________________________

Any new positive behaviors or skills? __________________________________________

Any side (adverse) effects (known or suspected)? __________________________________

Do you have any ideas/clues about the cause of your child's problem?
___no idea  ___yeast   ___vaccination   ___diet   ___other_______________________

What other therapies are being used?__________________________________________________