Necip Cem KINACI, MD
President & Medical Director of Autism Medical Institute  
Nuclear Medicine & Holistic Medicine Specialist, 
Diploma No: 17882 / 21350
Istanbul, Turkey

PERSONAL INFORMATION	
Date Questionnaire Received :   ___ /___ /               Date of Initial Consultation:   ___ / ___ / 2020	
[The above line is for office use only]	
Child's Name: First:                                               Last:                                       Middle Initial:	
Parent(s) Name(s): Mother : 	
                                  Father :	
Address: Street:                                                                                                     	
State/Country:                                                    City:                                  Phone: (       )      	
Work Phone: (       )                                                                       Cell: (       )    	
E-MAIL:                                                                   Fax: (       )	
Child's birth date: Month:                    Day:          Year               Child's Sex (Circle One): Female    Male	
Social Security Number (Optional):                                               Child's weight :  …kg       height:   …cm	
Primary Care Physician:  Name:                                                                                      City:  	
State:                                       Zip:                      Phone #: (       )                                      Cell #:(       )	
Health insurance:                                               ID No.:	
Referred by: 	
Siblings:   Name:                          Sex: (Circle One)   	
                                                        Male. Female        Month:                   Day:                    Year:	
Male. Female         Month:                   Day:                    Year:	
Male. Female         Month:                   Day:                    Year:	
Parent's occupation(s):  mother:                                                                father:	
Note: Please bring a fairly recent picture of your child that we may keep plus a baby picture that we 	
may look at and return.	
Diagnoses or explanation given to you about your child (Date of diagnoses)	

	
	
Other problems to be addressed:	

PERSONAL INFORMATION (Continued)	
Describe your child to me, including his her history. Please be as detailed as possible.	

 	

•   When did you first notice your child's problem?	

	
•   What did you first notice?	

	
•   Was the onset of your child's problem sudden or gradual?	

	
•   Was there any event or illness that you or others think brought on your child's syinproms?	

	
Please make notation of any other event, action, etc. that you think may have some bearing/	
relationship to your child's condition. Again, be as detailed as possible and do not hesitate to mention	
anything, no matter how small or insignificant, that you believe is related to your child's problem(s):	

	

CHILD'S MEDICAL HISTORY	
PRIMARY DOCTOR (S)	
Name	Phone Numbers	City	

			
THERAPIST(S)
Speech - Occupational - Physical -Other	
Name	Type of Therapist	Phone	City	Hours Week	

						
Other Care-Givers	
Name	Phone	City	Date of Evaluation	
Specialist (s)	

				
Naturopath (s) Homeopath (s)	

Nutritionist	
				
Other	

PRENATAL HISTORY	
Maternal age at delivery;              	
Illnesses during pregnancy:        	
	
Medication during pregnancy:    	
	
Other complications during pregnancy;	

Complications during labor and delivery:	

Mode of delivery: C-section vaginal?  If C-section, explain why:	

If vaginal delivery, did you have forceps/vacuum?	
 	
Medication(s) during labor and delivery?	

Full term premature?                       How many weeks?		
Complications after delivery?	
	
Medications given to child dining hospital stay?      	
 
DIETARY/NUTRITIONAL HISTORY	
Breast-fed?  :           If yes, how long? 
Bottle-fed? Brand of formula? _______ Begun at what age?                                                                                For how long?  
Foods? Begun at what age?   First foods?   Fruit mash.	
Whole milk?                  If yes, begun at what age?    
Known allergies to food? (Please list):   	
Suspected sensitivities to foods? (Please list):    
	
Food cravings? (Please list):   
	
Foods my child eats: (Place √ in appropriate column)	
Food	Daily	3-5 times/ week	1-3times/ week	Never or almost never	Used to eat a lot hut no longer does	
Cookies:						
Candy:						
Sweet foods:						
Caffeine (soda, tea, etc.):						
Chocolate:						
Milk:   Whole:						
2%:						
1%:	      					
Skim:						
Cheese:				             		
Ice Cream:						
Salty Foods:						
Meat:						
Pasta:						
Bread:   White:						
Wheat:						
Other:  integral	        					

DIETARY/NUTRITIONAL HISTORY (Continued)	
Check (√) the most appropriate description below of your child's diet; 
-	Mostly baby foods 
-	Mostly carbohydrates (bread, pasta, etc.) 
-	Mostly dairy (milk, cheese, etc.) 
-	Mostly meat 
-	Mostly vegetarian (vegetables, fruits, grains, etc.) 
-	Other. Describe:  Pasta, milk, chocolate, stews, soups, pizzas, fruit.	
	
Please describe your child's stool pattern (Examples; daily, foul, large, mushy, etc.);	

Please list the foods and beverages normally consumed by your child for three typical days:	
DAY 1	
Breakfast;    	
Morning snack(s):  	
Lunch:    	
Afternoon snack(s): 	
Dinner: 	
	
DAY 2	
Breakfast: 	
Morning snack(s): 	
Lunch: 	
Afternoon snack(s): 	
Dinner: 	
Other: 	
DAY 3 	
Breakfast:  	
Morning snack(s): 	
Lunch: 	
Afternoon snack(s): 	
Dinner: 
	
FAMILY HISTORY	
List any allergies, major illnesses, genetic diseases or problems (diabetis, astma, cancer, high blood pressure, heart disease, neurologic disease ?) for each of the following family members of your child:	
Mother: 	
Father: 	
Siblings: 	
Maternal Grandparents: 	
Paternal Grandparents: 	
Others: None.	
SOCIAL HISTORY	
Who lives in the home with your child: 	
Are any children in your family adopted?    	
Pets in the house:  	
Caregivers besides parents: 	
List the people most important in your child's life: 	
Recent changes, losses, births, deaths, divorce, remarriage or moves:	
Recent travel: 	
Child's response to these changes:  	
Is your child involved in any sports, music or other activities? Please describe: 	
How does your child interact with other children? 	
• With adults: 	
•What makes your child happy? 	
•Sad? 	
•Angry? 	
•Stressed? 	
•How do you as a parent deal with these emotions in your child? 
	
ENVIRONMENTAL HISTORY	
Do you, your child, or any family members practice any relaxation/stress management techniques? Please describe; 	
CIRCLE THE APPROPRIATE ANSWERS TO THE FOLLOWING QUESTIONS:	
Location of home: City/Suburban/Wooded/Farm          Other (describe): Suburban	
Water:   City/well                 Purification system: Yes/No    If yes, please describe: 	
Type of heat: Electric/gas/oil/other      If other, please describe: 	
Do you live near:  Power lines Avoids/industrial areas/Water?	
If you live near water, list type: Swamp/river/ocean/other   If other, please describe:	
Does your home have a lot of: Dust/mold /down or feather items (pillows, upholstery, stuffed animals?) If, so, please give details: 	
Describe your child's bedroom (Circle appropriate response): 	
Bedding: Synthetic/down/feather?              Mattress cover: Yes/No             Crib/Junior Bed /Adult Bed	
Flooring: Caipet: Wall-to-wall or area rug?            Wood?               Glued down?                Synthetic pad?                                                     	
Window treatment: Shades/blinds/thin      curtain/heavy curtain/valance/other?    If other, describe:  	
Other items in room including furniture, toys, stuffed animals: 	
Flooring in other rooms: 	
Child's bathroom? 	
Living room? 	
Family room/play room? 	
Is your child sensitive to or bothered by any of the following? Please check where appropriate and list specific products if possible:	
Perfumes/cosmetics?                                                 Mold?                      	
Cleaning products?                                                   Pollens grasses?  	
Soaps?                                                                        Animals (dander)?  	
Detergents?                                                                Gasoline?                  	
Dust?                                                                           Paint?                      	
Other?	
Please list known allergies:	
DEVELOPMENTAL HISTORY	
Please list age when following skills were mastered and any problems associated with these skills:	
First words: (Age:) 	
Phrases or sentences: (Age:) 	
Pulling to stand: (Age:)  	
Walking: (Age:)  	
Sitting up: (Age:)  	
Crawling: (Age:)  	
Running: (Age:)  	
Walking up/down steps without help: (Age:)   	
Jumping: (Age:)  	
Learned to pedal: (Age:)  	
Rode 2-wheel bicycle: (Age: )  	
Put on clothing: (Age: )  	

MEDICAL HISTORY	
Please mark which tests have been done and provide date and results	
Evaluation Test	Date		
24 Hour Amino Acids			
Amino Acid Screen			
Blood Chemistry Screen			
Blood Count (CBC)			
Blood Test—Fatty Acid			
Blood Test—Food Allergies			
CT Scan (specify area)			
Colonoscopy	 		
DMSA Loading Study			
EEG		 	
Folic Acid			
Fragile X Chromosome Study			
Hair Elements			
Hearing Test			
Immune Profile			
Intestinal Permeability			
Liver Detox Profile			
MRI (specify area)			
Organic Acids—fungal bacteria			
Organic Acids—Metabolism			
Brain SPECT Scan			
MEDICAL HISTORY	
Please mark which tests have been done and provide date and results	
Evaluation Test	Date	Results (normal, abnormal or unsure)	
Pinworm Prep			
Plasma Amino Acids			
Plasma or Serum Zinc			
RBC Elements			
Serum Ferritin (Iron stores)			
Serum Methylmalonic Acid			
Serum Vitamin A			
Small Bowel Biopsy			
Stool Culture			
Stool Parasites			
Thyroid Profile			
Uric Acid (blood or urine)			
Urinary Peptides			
Urine Elements			
Urine KryptopyiTole			
X-Rays (specify)			
Zink (blood)			
Lithium (blood)			
Ammonia (blood)			
Other:			

MEDICAL HISTORY (Continued)	
Major surgeries - Please describe and give dates:	
SURGERY	DATE(S)	RESULTS	

			
Major injuries - Please describe and give dates:	
INJURY	DATE(S)	RESULTS	

			
Illnesses - Please list appropriate dates and any complications:	
ILLNESS	DATE(S)	COMPLICATIONS	
Ear infections			
Sinus infectious			
Bronchitis			
Pneumonia			
Thrush			
Chicken Pox			
Seizures			
Mono			
Other: (Please list):			

Immunizations	
Please indicate date and any reactions for those immunizations that your child has received. If exact date isn't known, please approximate. "Bowel" refers to any bowel symptom such as diarrhea.
"Swelling" refers to the site of the injection.	
Diptkei in Pertussis Tetanus	Date	Bowel	Swelling	Crying	Seizure	Irritable	Fever	Other	
DPT 1									
DPT 2									
DPT 3									
DPT 4									
DPT 5									
Adult DiptherkTetanus									
Peadiatric Diptheris/Tetanus									
H Influenza Type B	Date	Bowel	Swelling	Crying	Seizure	Irritable	Fever	Other	
Hibl									
Hib 2									
Hib 3									
Hib 4									
Polio (circle oral or Injection.)	Date	Bowel	Swelling	Crying	Seizure	Irritable	Fever	Other	
OPV 1 Iuiection 1									
OPV 2/Injection 2									
OPV 3/Injection 3									
OPV 4/ Injection 4									
OPV 5/ Injection 5									
Measle s/JVIumps/Rubella	Date	Bowel	Swelling	Crying	Seizure	Irritable	Fever	Other	
mmr1									
mmr:									
Hepatitis b V accine	Date	Bowel	Swelling	Crying	Seizure	Irritable	Fever	Other	
HBV1									
HBV2									
HBV3									
Prevnar (pnemococcal)									
Miscellaneous	Date	Bowel	Swelling	Crying	Seizure	Irritable	Fever	Other	
Varivax (chicken Pox)									
Troe Test									
Flu Vaccine									
Other									

									

Medication or Supplements	
Please check (√) substances takeu now or iu the past and mark the appropriate reaction	
now	past	Medication or Supplement	Very
Good	Good	None	Bad	Very Bad	Bad then
Good	Comments	
										
		Clozaril (clozapine)								
		Haldol								
		Prohxni								
		Risperdal								
		Seroquel								
		Stelazine								
		Thorazine								
		Zyprexa								
		Clonidine								
		Cogentin								
		Deanol (deaner, DMAE)								
		Dextromethorphan								
		Lithium								
		Naltrexone								
		Anafianil								
		Depakene for behavior								
		Depakene for seizures								
		Depakote for behavior								
		Depakote for seizures								
		Dilantin								
		Felbatol								
		Gabitril								
		Keppra								
		Klonopin								
		Lamictal								
		Luvox								
		Mysoline								
Medication or Supplements	
Please check (√) substances taken now or in the past and mark the appropriate reaction	
now	past	Medication or Supplement	Very Good	Good	None	Bad	Very Bad	Bad then Good	Comments	
										
		Neurontin								
		Paxil								
		Phenobarbital								
		Stratena								
		Tegretol								
		Topamax								
		Trileptal								
		Valium								
		Zarotin								
		Zonegran								
		Adderall								
		Prozac								
		Zoloft								
		Amphetamine								
		Cylert								
		Dexedrme, dextroamphetamine								
		Fenfluramine								
		Focalir.								
		Ritalin								
		Buspar								
		Chloral hydrate								
		Valium								
		Desipramine								
		Mallaril								
		Tofranil								
		Klonapin								

Medication or Supplements	
Please check (√) substances taken now or in the past and mark the appropriate reaction	
now	past	Medication or Supplement	Very Good	Good	None	Bad	Very Bud	Bad then Good	Comments	
		Benadryl								
		Clantin								
		Singulair								
		Zyrtec								
		Digestive Flora								
		Bactrim (septra)								
		Diflucan								
		Humatin								
		Lamisil								
		Nizoral								
		Nystatin								
		Saccharomyces, boulardii								
		Sporonax								
		Transfer Factor (oral). Colostrum								
		Yodoxin								
		Digestion								
		Bethenecol								
		Digestive enzymes								
		Pepsid								
		Peptidase enzymes								
		Probiotics								
		DMPS								
		DMSA 		  						
		Reduced glutathione (TTFD)								
		Reduced glutathione (IV)								
		Reduced glutathione (oral)								
		Folic Acid		  						
		Melatonin								

Medication or Supplements	
Please check (√) substances taken now or in the past and mark the appropriate reaction	
now	past	Medication or Supplement	Very Good	Good	None	Bad	Very Bad	Bad theu Good	Comments	
										
		Multivitamin (Specifiy)								
		Vitamin A								
		Vitamin C		   						
		Vitamin B3 (Niacin)								
		Vitamin B6		   						
		5 HTP								
		Alpha Keto Glutarate (AKG)								
		Amino Acid Mix								
		Deanol								
		Dimethylglycine (DMG)								
		GABA								
		Glutamine								
		SAMe (SAM, Samyr)								
		TMG								
		Taurine								
		Tryptophan								
		Tyrosine								
		Calcium		   						
		Magnesium								
		Manganese								
		Selenium								
		Zinc		   						
		Human Growth Factor								
		IV Immune globulin								
		Kutapressin								

Medication or Supplements	
Please check (√) substances taken now or in the past and mark the appropriate reaction	
now	past	Medication or Supplement	Very Good	Good	None	Bad	Very Bad	Bad then Good	Comments	
										
		Oral Immune globulin								
		Secretin (IV)								
		Secretin (transdermal sublingual)								
		Steroids (oral)								
		Steroids (topical)								
		DHA rich oils								
		EPA rich oils								
		Omega 6 rich oils								
		Cod liver oil								
		Flax oil								
		Other								
		Activated Charcoal								
		AlkaGold								
		Carbatrol								
		Tranxene								
		Famvir								
		Valtrex								
		Zovirax								
		OTHER: 								

										

										

Therapies and Diets	
Please indicate therapies and diets you have used and/or are using.	
now	past	Therapies	Very Good	Good	None	Bad	Very Bad	Bad then Good	Comments	
		Acupuncture								
		Auditory Training								
		Craniosacral								
		Energy Therapy (Specify)								
		Homeopathy								
		Lovaas (ABA)								
		Naturopathy								
		Neural Therapy								
		Occupational Therapy								
		Osteopathy								
		Physical Therapy								
		Sensory Diet								
		Speech Therapy								
		Hyperbaric Oxygen Theraphy							Number of sessions:	
		Genetic By-pass								
		Biofilm treatment								
		Other:								
										
		Diets								
		Gluten Free								
		Casern Free								
		Yeast Free								
		High Protein/ Low Carb								
		Salicylate Free								
		Low Phenolics								
		IgG reactive food avoidance								
		Specific Carbohydrate Diet								
		Other:								
SIGNS AND SYMPTOMS	
Please check (√) any signs/symptoms your child may demonstrate and note duration
and details if appropriate:	
No.	Description	Mild	Moderate	Severe	Duration	Unique details	
1	Stimming (repetitive actions or movements)						
2	Rocking						
3	Head banging						
4	Self-mutilation						
5	Nail biting						
6	Hand/arm biting						
7	Nail/skin picking						
S	Aggressiveness (hitting, kicking, biting others)						
9	Mood swings						
10	Irritability/tantrums						
11	Fears/anxieties						
12	Hyperactivity						
13	Inability to concentrate/focus						
14	Always fidgety in his/her seat						
15	Impulsive						
16	Breath holding						
17	Dizziness						
18	Seizures						
19	Poor coordination						
20	Problems with buttons, ties, snaps or zippers						
21	Processing problems - visual, motor, language, etc.						
22	Problems with social interactions						
23	Sensitive to crowds						
24	Trouble remembering						
25	Low self-esteem						
26	Fatigue						
27	Cold hands/feet						
SIGNS AND SYMPTOMS (Continued)	
Please check (√) any signs/symptoms your child may demonstrate and note duration
and details if appropriate:	
No.	Description	Mild	Moderate	Severe	Duration	Unique details	
28	Cold intolerance						
29	Heat intolerance						
30	Recurrent/chronic fever						
31	Flushing						
32	Difficulty falling to sleep						
33	Night waking						
34	Nightmares						
35	Difficult)’ waking						
36	Bed wetting, soiling						
37	Day time wetting/soiling						
38	Numbness/tingling in hands/feet						
39	Headache						
40	Blinking						
41	Tics						
41	Eye discharge						
43	Dark circles’puffuiess under eyes						
44	Night-blindness in child/family						
45	Congestion						
46	Dripping nose						
47	Sensitivity to bright lights						
48	Earaches						
49	Ringing in ears						
50	Sensitive to sounds/noise						
51	Bad breath						
52	Nose bleeds						
53	Acute sense of sraeU						
54	Sore throats						
55	Hoarseness						
56	Cough						
SIGNS AND SYMPTOMS (Continued)	
Please check (√) any signs/symptoms your child may demonstrate and note duration
and details if appropriate:	
No.	Description	Mild	Moderate	Severe	Duration	Unique details	
57	Wheezing						
58	Geographic tongue						
59	Swollen gums						
60	Canker sores						
61	Dry lips/mouth						
62	Diarrhea						
63	Constipation						
64	Bloating						
65	Passing gas						
66	Belching						
67	Stomach ache						
68	Refusal to eat						
69	Sensitive to texture of food						
70	Difficulty swallowing						
71	Food Craving						
72	Grinding teeth						
73	Mucous/blood in stools						
74	Anal itching						
75	Calf cramps						
76	Other muscle cramps/spasms						
77	Tremors						
78	Weakness						
79	Stiffness						
80	Eczema						
81	Psoriasis						
82	Hives						
83	Acne						
84	Seborrhea (cradle cap)						
85	Other rashes						
SIGNS AND SYMPTOMS (Continued)	
	
No.	Description	Mild	Moderate	Severe	Duration	Unique Details	
86	Easy bruising						
87	Itchy scalp						
88	Dry skin						
89	Oily skin						
90	Pale skin						
91	Sensitivity to insect bites						
92	Sensitive to texture of clothes						
93	sensitivity to the fabric of the clothes						
94	Cracks in the skin on the hands and feet						
95	Strong body odor						
96	Strong urine odor						
97	Strong stool odor						
98	Soft nails						
99	Thickening of nails						
100	Ridges/pitting of nails						
101	White spots/lines on nails						
102	Brittle nails						
103	Any OCD (obsessive compulsive) behaviors						
104	Strategies to put pressure On abdomen						
105	Reflux						
106	Persistent colic						
107	Toe walking						

SIGNS AND SYMPTOMS (Continued)	
Describe any other symptoms you would like me to know about your child:	

	
	
List any other history, pertinent thoughts or questions that you want to address:	

	

	

Please send back to : cemk.sen@gmail.com
Please print this questionnaire and bring it to your doctor’s office !