--CHELATION SURVEY FORM. Directions for use of this form are located here: -- http://groups.yahoo.com/group/Autism-Mercury/files/Survey_directions --SECTION 1: SURVEY INFO: --Name of person filling out survey: --Please list email addresses you've used to post to the autism-mercury list: --Are you willing to answer email questions about your chelation experiences? --Are other family members also being chelated? --What is your state or country of residence (this is merely for "curiousity"): --REGARDING THE PERSON BEING CHELATED...... --Date started chelation: --Age at start of chelation: --Date today: --Age today: --SECTION 2: GENERAL HISTORY prior to chelation: --Diagnoses and age(s) at these diagnoses. (Include comments on dx if you wish): --Age when "regression" became apparent (if applicable): --ATEC score prior to chelation (if known): --Other health problems prior to chelation: --Comments on health prior to chelation: --If hair test prior to chelation is available, what metals are high? --Date of test? What lab? --Does test show "disordered mineral transport" (counting rules) (if applicable): --Other relevant test results prior to chelation: --What other interventions or treatments were used PRIOR TO chelation: --On GFCF diet prior to chelation? If yes, for how long? --SECTION 3: MERCURY EXPOSURE and VACCINE REACTIONS --List vaccinations received and age: --Any noticeable/immediate vaccine reactions? --Number of amalgam "silver" fillings (in person being chelated): --When was amalgam replacement completed (if applicable)(date): --Number of amalgam "silver" fillings present in the biological mother during gestation: --Any dental work done on mother during gestation (amalgam placed, or replaced): --Any vaccinations or Rhogam injections of biological mother during gestation? --How long breastfed (if known): --Any comments on sources of mercury exposure or exposures to other metals: --SECTION 4: CHELATION METHODS USED (Please answer in detail) --Chelation agent(s) used: --Dose (amounts per dose): --Weight of person chelated: --Dose schedule (how often are doses given): --Cycle length (how many days on/off): --How many rounds/cycles of chelation have been completed: --Are you still chelating? --If multiple chelation agents or multiple protocols or methods have been tired, --please comment on differences or similarities noted: --SECTION 5: EFFECTS OF CHELATION --Please list changes you have noticed since starting chelation: --Do you believe these changes are from chelation? --How chelation has effected your child, yourself, your family: --Using one the following ratings, what is the OVERALL effect of chelation, so far: --RATINGS: 7: extremely negative effect; 6: very negative effect; 5: somewhat negative effect; --4: neutral; 3: somewhat positive effect; 2: very positive effect; 1: extremely positive effect --ATEC scores during/after chelation (if known): --If a hair test is available from during/after chelation, any change noted? Date of test? --Other test results from during or after chelation? Date of test? (If excretion test, --what metals were being excreted?) --Issues/symptoms which have NOT been changed by chelation: --Please comment on side effects and problems during chelation: --Comment on treatments used for side effects: --Supplements used during chelation (please list) --Supplements added/deleted (and reason for adding/deleting): --What other interventions or treatments used DURING chelation: --GFCF during chelation? --SECTION 6: MISC QUESTIONS --If you have stopped chelation, how did you decide to stop? --Would you recommend chelation to others? --Do you have a doctor (or health provider) assisting you with chelation: --Please describe the role of health provider (e.g. directing, monitoring, other): --Any comments on your doctor or other health providers, relative to chelation: --Are you willing to discuss your health provider(s) (in private mail)? --Anything else you would like to add?