Secrenase Initial Assessment Form

The scale is from 1-10 with 5 being a 'neutral' position - that is to say that you consider them to be about 'normal' in that category. The lower the number, the worse rating you would give. For example, consider your child's response to injury - if they never cry in pain, that is to say their pain tolerance is high, then you would score pain response at 1 or 2. If they have normal pain levels they would score 5. Over sensitive to pain might score 9 or 10.

Consider sleep - if they only sleep for a few hours you might give them a score of 4, if they don't sleep at all then a score of 1, if they sleep 8 to 10 hours at night then a score of 5 or 6 and so on.

Don't worry too much about being perfectly accurate, this is only to get some idea of the starting point and so that we can easily rate and monitor their progress.

* Required fields
Name *
E-mail Address *
What is your child's name *
What is your child's age? *
Please provide a contact telephone number *
What if any, treatments or supplements is your child already receiving? *
Please score your child's speech between 1 and 10 *
Is your child's concentration *	Good Bad Normal
Please score your child's concentration between 1 and 10 *
Are your child's play and social skills *	Good Bad Normal
Please score your child's play/social skills between 1 and 10 *
Is your child's pain response *	High Low Normal
Please score your child's pain response between 1 and 10 *
Is your child's sleep *	Good Bad Normal
Please score your child's sleep between 1 and 10 *
Are your child's bowel movements *	Good Bad Normal
Please score your child's bowel movements between 1 and 10 *
Is your child's toilet training *	Good Bad Normal
Please score your child's toilet training between 1 and 10 *
Is your child's diet *	Good Bad Normal
Please score your child's diet between 1 and 10 *
Is your child's behaviour repetitive or ritualistic *	Good Bad Normal
Please score your child's repetitive or ritualistic behaviour between 1 and 10 *
Does your child suffer have hand flapping behaviour? *	Good Bad Normal
Please score your child's hand-flapping behaviour between 1 and 10 *
Your child's eye contact *	Good Bad Normal
Please give an assessment of your child's overall awareness *	Good Bad Normal
Please indicate your child's eye contact rating i.e 1 bad - 5 normal - 10 good *
Please score your child's overall awareness between 1 and 10 *
Does your child have speech? *	Yes No

I have read and agree to the Privacy Policy *

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