Worksheet

Nutrition Assessment

Filling out this worksheet will give you an idea of where your child ranks regarding the various behaviors, signs and symptoms considered on the autism spectrum.

When you get to the bottom, click the "Save Worksheet" button to be taken to our online calendar to schedule your coaching call.

1. ➜

Please complete these questions, to the best of your ability.

We ask you to fill out this form so we can help YOU and YOUR CHILD better.

Please fill it out as completely as possible. It will help give us ideas for your child's nutrition!

2. ➜

Today's Date*

3. ➜

Parent(s) name*

4. ➜

Email address*

5. ➜

SMS/text Phone number*

6. ➜

Child's name (or children who will be doing the protocol)*

7. ➜

Child's (children's) age(s)

8. ➜

Please upload a picture and/or 1-2 min video of your child here.

Attach file

9. ➜

Please complete this multi-page assessment. Then upload it here.

FullAssessmentForm-0722.pdf

This helps Luminara to better understand your child and his or her issues as we move forward in the program.

You can come back to edit this entire form and upload this PDF later.

Please make sure all sections have a total number at the bottom. If they do not, please add your totals and either write them in at the bottom of this assessment or take a photo and upload those. It's essential we have the totals on your sheet added up. Thank you!

Attach file

10. ➜

Please upload a 1-2 minute video of your child here.

This helps Luminara to better understand your child and his or her issues as we move forward in the program.

Attach file

12. ➜

Anything else you want to say about overall health?

13. ➜

Body Energy

seems wired but tired a lot

lethargic, listless

doesn't run, play, keep up on walks

low muscle tone

floppy body

seems to be always moving, hyperactive and random movements

14. ➜

Anything else you want to say about body energy?

16. ➜

Anything else you want to say about allergies and sensitivities?

Please let me know if you've done testing for this and how long ago. Was it recent, in the last year? Or was it several years ago?

18. ➜

Anything else you want to say about your child's digestion?

19. ➜

Please list typical foods your child eats for BREAKFAST

Being as specific as possible (even naming brands you use) can be very helpful.

20. ➜

Please list typical foods your child eats for LUNCH

Being as specific as possible (even naming brands you use) can be very helpful.

21. ➜

Please list typical foods your child eats for DINNER

Being as specific as possible (even naming brands you use) can be very helpful.

22. ➜

Please list typical foods your child eats for SNACKS

Being as specific as possible (even naming brands you use) can be very helpful.

23. ➜

Pooping frequency

less than once per day

once per day

2-4 times per day

more than 4 times per day

24. ➜

Choose the type of poop your child has most consistently.

bristolpoopchart

1 separate hard lumps, like nuts, hard to pass

2 sausage-shaped but lumpy

3 like a sausage but with cracks on the surface

4 like a sausage or snake, smooth and soft, easy to pass

5 soft blobs with clear cut edges, easy to pass

6 fluffy pieces with ragged edges, mushy

7 watery, no solid pieces, all liquid

8 a mixture of different forms of stools on different days

25. ➜

Anything else you want to say about your child's elimination or what the poop looks like?

26. ➜

Sleep

has a hard time falling asleep

wakes during the night and may stay asleep for a while

doesn't sleep enough for their age

sleeps too much for their age

27. ➜

Anything else you want to say about sleep?

28. ➜

Urinary

excessive thirst

frequent urination

painful urination

wets the bed at night

wets during the day

isn't at all interested in going on the potty

29. ➜

Anything else you want to say about urination?

This would be a good place to say if your child is prone to UTIs, has had surgery related to bladder or penis or other urinary issues.

30. ➜

Nervous system

delayed hearing confirmed by testing

delayed hearing - suspected

known auditory integration issue

seizures

epilepsy

seeks sensory stimulation - touch, pressure, etc

stimming behavior (repeats the same sounds, flaps hands or arms, waves fingers in front of eyes, performs actions repeatedly)

tics

31. ➜

Anything else you want to say about the nervous system?

This would be a good place to write anything a neurologist did or told you, any type of brain scans, sensory processing disorder (which usually looks like responding slowly to name or requests, as it takes a lot of time to process), etc.

32. ➜

Speech

non-verbal, doesn't speak words

verbal, but words aren't clear

verbal, can say 3 or more words together to express needs

33. ➜

Anything else you want to say about speech?

This would be a good place to expand on experience with speech therapy, whether or not it helped, or anything else related to speech, such as unable to get words out but tries, unable to answer yes/no appropriately, etc.

34. ➜

Sensory Motor

difficulty chewing

toe walking

difficulty with stairs

difficulty with gross motor skills (jump, skip, hop, run)

difficulty with fine motor skills (handwriting, holding pencil, tying shoes)

difficulty crossing the midline (for example, right hand touching left side of body)

35. ➜

Anything else you want to say about motor activities or sensory issues?

This would be a good place to write about if your child is sensory seeking and what does that look like? If there are particular difficulties with movement or coordination.

36. ➜

Emotional

anxiety

OCD (obsessive compulsive disorder - has to have things in the room just in the right place)

lots of frustration

gets angry a lot/tantrums (not appropriate for the circumstance)

cries for long periods

37. ➜

Anything else you want to say about your child's emotional challenges or responses to emotional times?

38. ➜

Hearing

seems spacey

doesn't respond to name being called

doesn't answer questions appropriately

doesn't make eye contact, or not often

echolalia (repeats what is heard vs responding appropriately to a question)

doesn't answer yes and no appropriately

has had tube (grommets) put in ears to help with hearing

has had more than 1 ear infection

39. ➜

Anything else you want to say about hearing?

This would be a good place to write if you know or suspect your child has delayed hearing or vestibular/balance issues.

40. ➜

Respiratory

asthma

wheezing

history of nebulizer/steroids

current use of nebulizer/steroids

frequent congestion in chest

frequent congestion in nasal/sinuses

41. ➜

Anything else you want to say about the respiratory system of your child?

42. ➜

History of Injections

had all vaccinations

had some vaccinations then stopped

had reaction to vaccinations (fever, crying, discomfort, redness, etc)

has had injections other than vaccinations

has had anesthesia for dental work

has had anesthesia for other body procedures

has had surgery(ies)

43. ➜

Anything else you want to say about your child's history of injections?

This would be a good place to describe any type of adverse reaction to vaccines, anesthesia, dental work, surgeries, including digestive troubles after any of these events.

44. ➜

My child takes medication

Please list the prescription medications and dosage your child takes now. And keep in mind that by cleaning up his or her body, the need for medication may decrease or be eliminated. Be sure to have regular check-ups with your prescribing doctor to be sure your child's dosage is correct.

45. ➜

My child takes supplements/vitamins

Please list the main supplements your child takes regularly. And keep in mind that by cleaning up his or her body, the need for supplements may diminish. It's something you will want to watch as you go through the protocol.

46. ➜

My child is on a special diet

Please list your child's diet or foods s/he must avoid. If there are many, list the biggest offenders. You will likely find over time, going through the protocol, this will shift.

47. ➜

Please take a picture of your child's current supplements and upload here.

Attach file

48. ➜

Please take a picture of your child's PAST supplements and upload here.

Attach file

49. ➜

Please tell us about your child's gestation period while mom was pregnant

Was there stress or trauma - for the child or mom, natural birth or c-section, medications involved?

50. ➜

Was the child breast fed?

Yes

51. ➜

Any comments about breast feeding?

52. ➜

Anything else you want to mention?

If there is something we haven't asked about, but you feel it is a significant challenge for your child or your family, please list it here.

53. ➜

Upload any other documents you'd like me to see.

Attach file

54. ➜

Thank you! Book your 50 minute Nutrition Consult.

You've reached the end of this form. Thank you for being thorough!

If there are more things you remember, you can always come back and add more to the assessment.

Click here to schedule your appointment.

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Autism Transformed, LLC

Nutrition Assessment

Please complete these questions, to the best of your ability.

Today's Date*

Parent(s) name*

Email address*

SMS/text Phone number*

Child's name (or children who will be doing the protocol)*

Child's (children's) age(s)

Please upload a picture and/or 1-2 min video of your child here.

Please complete this multi-page assessment. Then upload it here.

Please upload a 1-2 minute video of your child here.

Overall Health

Anything else you want to say about overall health?

Body Energy

Anything else you want to say about body energy?

Allergies/Sensitivities

Anything else you want to say about allergies and sensitivities?

Food/Digestive

Anything else you want to say about your child's digestion?

Please list typical foods your child eats for BREAKFAST

Please list typical foods your child eats for LUNCH

Please list typical foods your child eats for DINNER

Please list typical foods your child eats for SNACKS

Pooping frequency

Anything else you want to say about your child's elimination or what the poop looks like?

Sleep

Anything else you want to say about sleep?

Urinary

Anything else you want to say about urination?

Nervous system

Anything else you want to say about the nervous system?

Speech

Anything else you want to say about speech?

Sensory Motor

Anything else you want to say about motor activities or sensory issues?

Emotional

Anything else you want to say about your child's emotional challenges or responses to emotional times?

Hearing

Anything else you want to say about hearing?

Respiratory

Anything else you want to say about the respiratory system of your child?

History of Injections

Anything else you want to say about your child's history of injections?

My child takes medication

My child takes supplements/vitamins

My child is on a special diet

Please take a picture of your child's current supplements and upload here.

Please take a picture of your child's PAST supplements and upload here.

Please tell us about your child's gestation period while mom was pregnant

Was the child breast fed?

Any comments about breast feeding?

Anything else you want to mention?

Upload any other documents you'd like me to see.

Thank you! Book your 50 minute Nutrition Consult.

Save your answers