--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?