Dear Parent

Completion of this form will help us to monitor your child's progress.  Please complete the form on a regular basis at the end of each month of treatment.  We can then produce an overall progress rating which will help in deciding whether to recommend a change of dosage of Secrenase or any changes in treatment protocol.

Please select the number of the form below that you feel best reflects your child's response -

As an example, take sleep - if your child's sleep pattern is the same as last month (or at registration) then select 0.  If your child is sleeping slightly better, then perhaps select +2, if significantly better - then +4 and if the same pattern is much worse then select -2 etc.

You will notice that pain tolerance is the opposite way round - so if your child seems to feel no pain at all you would select the -5, if he/she begins to register pain then you would gradually score more of a + value and once your child responds in the same way as any other child then a +5 score.

* Required fields
Name *
E-mail Address *
Name of child *
Date of completion of form *
Months on therapy *
Your child's current weight in kilos *
Eye contact *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Overall awareness *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Speech *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Concentration *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Play *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Social skills *	-5 -4 -3 -2 -1 Worse 0 same +1 Better +2 +3 +4 +5
Pain response *	-5 -4 -3 -2 -1 Worse 0 same +1 Better +2 +3 +4 +5
Sleep *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Bowel movements *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Toilet Training *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Diet *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Hand flapping *	-5 -4 -3 -2 -1 Worse 0 Same +1 Better +2 +3 +4 +5
Ritualistic/Repetitive behaviour *	-5 -4 -3 -2 -1 Worse 0 same +1 Better +2 +3 +4 +5
How there been any significant developments in the past month? *
Have you had/have there been any difficulties with the therapy? *
Would you like to change the dosage of Secrenase? *
Do you have any general comments you would like to make? *

I have read and agree to the Privacy Policy *

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Thank you for taking the time to complete this form and helping us to help you.