Study #191

191

I am representing myself or my child/grandparent/other in this study: 
I am representing myself in this study
Gender of Participant: 
Male
Age of Participant: 
87
Nationality of Participant (select from list provided): 
United States
Category of Participant (choose one selection): 
Received standard vaccinations (full schedule of shots) between 0-7 years; also officially diagnosed with Autism Spectrum Disorder
Symptoms of Autism Spectrum Disorder noted (choose all symptoms exhibited by participant if applicable): 
chronic rash
chronic eczema
Gastroenteritis
floppy limbs
cracking of joints
Glutathione deficiency
chronic constipation
chronic diarrhea
Inflammatory Bowel Disease (Crones, Colitis)
Sub-Clinical Epileptic Seizures
Grand Mal Epileptic Seizures
Macrophagic myofascilitis
Chronic Fatigue Syndrome/Fybromyalgia
chronic Insomnia
rolling on the back
refusal to lay on stomach
fanning or shaking of hands
fixation on ceiling fans
fixation on repetitive motions
spinning in circles repeatedly
tearing up paper repeatedly
long stretches of silence/withdrawal
complete absence of speech/verbal communication
acute difficulty relating to people/objects/events
indications of mental developmental delays
indications of physical developmental delays
serious mental & physical developmental delays
prolonged difficulty using/understanding language
acute sensitivity to sound/light/surroundings
unusual/obsessive play with toys & other objects
difficulty with changes in routine or familiar surroundings
circumscribed interests are more prominent (ie. cars, trains, door knobs, hinges, meteorology, astronomy or history)
Attention Deficit Disorder (symptoms include inattentiveness, hyperactivity, impulsiveness, easily distracted, fidgeting, excessively talkative, physically reckless, delayed social & motor skills, plus extreme sensitivity to sensory stimuli)
Attention Deficit Hyperactivity Disorder (symptoms include impulsiveness, hyperactivity, inattention, fidgeting, excessive talkativeness, impatience, physically reckless, delayed social & motor skills, plus extreme sensitivity to sensory stimuli)
Hypotonia (decreased muscle tone: the amount of resistance to movement in a muscle)
Echolalaia/Echophrasia (the immediate & involuntary repetition of words or phrases just spoken by others)
Echopraxia (the automatic repetition of movements made by another person)
Epstein Bar Virus (symptoms include fever, sore throat, swollen lymph glands, swollen spleen or liver)
Bacterial Meningitis (inflammation of the thin tissue that surrounds the brain & spinal cord, called the meninges)
Childhood Disintegrative Disorder (symptoms include sudden loss of motor/social/language skills, bowel & bladder control at age 2)
Encephalitis (symptoms include dizziness, confusion, vomiting, high fever, weakness or paralysis, impaired speech & hearing, delirium, excessive drowsiness, brain inflammation, coma)
Febrile Convulsions (symptoms include loss of consciousness, stiffening of the body, legs & arms, jerking of head, legs & arms, skin turning pale or blue)
Rett's Syndrome (symptoms include slowing of development, loss of purposeful use of the hands, distinctive hand movements, slowed brain & head growth, problems with walking, seizures & intellectual disability)
Mitochondrial Disorder (symptoms include muscular weakness/Hypotonia, developmental delays, epilepsy, vision & heart problems)
Multiple Chemical Sensitivity (acute sensitivity to commonly used chemicals products including perfumes, air fresheners & laundry softeners. The symptoms, which are chronic include fatigue and respiratory, digestive, cardiovascular, dermatological & neurological problems)
Symptoms of Autism Spectrum Disorder Noted Comments: 
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Age Autism First Appeared Comments: 
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Month Autism First Appeared Comments: 
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Immunization schedule of Participant - List all vaccines received from birth (choose all corresponding options if applicable): 
Hepatitis B - 1st dose (at birth)
Hepatitis B - 2nd dose (1/2 months)
Hepatitis B - 3rd dose (5/8 months)
Rotavirus - 1st dose (2 months)
Rotavirus - 2nd dose (3 months)
Rotavirus - 3rd dose (4/5 months)
DPT: Diphtheria, Pertussis, Tetanus - 1st dose (2 months)
DPT: Diphtheria, Pertussis, Tetanus - 2nd dose (3 months)
DPT: Diphtheria, Pertussis, Tetanus - 3rd dose (4/6 months)
DPT: Diphtheria, Pertussis, Tetanus - 4th dose (13/19 months)
DPT: Diphtheria, Pertussis, Tetanus - 5th dose (4/6 years)
MMR: Measles, Mumps, Rubella - 1st dose (12/15 months)
MMR: Measles, Mumps, Rubella - 2nd dose (4/6 years)
HIB: Haemophilus Influenzae Type b - 1st dose (2 months)
HIB: Haemophilus Influenzae Type b - 2nd dose (4 months)
HIB: Haemophilus Influenzae Type b - 3rd dose (12 months)
IPV: Inactivated Polio Vaccine - 1st dose (2/4 months)
IPV: Inactivated Polio Vaccine - 2nd dose (4/5 months
IPV: Inactivated Polio Vaccine - 3rd dose (5/18 months)
PCV: Pneumococcal Conjugate Vaccine - 1st dose (2/4 months)
PCV: Pneumococcal Conjugate Vaccine - 2nd dose (4/6 months)
PCV: Pneumococcal Conjugate Vaccine - 3rd dose (6/12 months)
PCV: Pneumococcal Conjugate Vaccine - 4th dose (12/18 months)
PCV: Pneumococcal Conjugate Vaccine - 5th dose (2/6 years)
Hepatitis A - 1st dose (12 months)
Hepatitis A - 2nd dose (18 months)
Hepatitis A - 3rd dose (2/6 years)
Varicella: Chickenpox - 1st dose (6/18 months)
Varicella: Chickenpox - 2nd dose (3/6 years)
Meningococcal - 1 dose (2/6 years)1 dose (28-36 weeks antepartum/postpartum)
Rhogam - 1 dose (28-36 weeks antepartum/postpartum)
Influenza - 1 annual dose
Vitamin K - 1 dose (at birth)
Other vaccine(s) received - specify
Immunization schedule of Participant Comments: 
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Pre-existing medical conditions/genetic predisposition of Participant (choose all corresponding options if applicable): 
Diabetic
Diarrhea
Gastroenteritis
Inflammatory Bowel Disease
food allergies
skin allergies
environmental allergies
Thyroid deficient/Hyper-Hypothyroid
Mercury Amalgam Fillings in teeth
Crones/Colitis
constipation
Mitochondrial Disorder
Dermatitis
Celiac Disease
anemic
asthmatic
heart condition
prone to weight gain
prone to weight loss
Hypotonia
organ problems
prone to colds/flu
resistant to colds/flu
Cancer/Leukemia
Lou Gerig's Disease/ALS
Lupus Disease
Mononucleosis
Fybromyalgia
Chronic Fatigue Syndrome
Chronic Bronchitis
Febrile Convulsions
Anaphylaxis
Bacterial Pneumonia
Encephalitis
premature hair loss
chronic ear infections
chronic headaches
Tourette's Syndrome
Sub-Clinical Epileptic Seizures
Grand Mal Epileptic Seizures
Multiple Chemicals Sensitivity
prescribed antibiotics
prescribed anti-viral drugs
prescribed anti-psychotic drugs
prescribed anti-depressant drugs
prescribed anxiolytic drugs
Medicated Birth Child (Pitocin drip/Pudental Block/Epidural/C-section)
Parkinson's Disease
Alzheimer's Disease
prone to Insomnia
chronic Insomnia
prone to Headaches
born with chronic/debilitating illness
developed chronic/debilitating illness
never had chronic/debilitating illness
Pre-existing medical conditions/genetic predisposition of Participant Comments: 
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Dietary/Health History of Participant (choose all corresponding options if applicable): 
dairy-rich diet
avoid milk/cheese products
avoid casein
gluten-rich diet (starchy foods)
avoid grains, pasta, white flour
avoid gluten
sugar-rich diet
avoid sugar
salt-rich diet
avoid salt
use iodized salt regularly
use sea salt regularly
use margarine regularly
use Crisco regularly
eat junk food regularly
eat fast food regularly
avoid junk food
avoid fast food
use corn syrup regularly
use fructose regularly
avoid fructose
regular smoker
avoid smoking
use flax/hemp/coconut oil
high-fibre diet
cook with poly-saturated fats
avoid using poly-saturated fats
use sugar sweeteners/Aspartame regularly
minimal exposure to sunlight
frequent exposure to sunlight
take Vitamin D3 supplement
meat-eater
vegan
vegetarian
semi-vegetarian
eat strictly organic food
eat non-organic food
eat soy products
regular alcohol user
recreational drug user
heavy drug user
regular caffeine user
drink pop regularly
consume Aspartame containing products
avoid Aspartame containing products
drink from plastic containers
avoid using plastic containers
use aluminum plates, cups, cutlery
avoid aluminum plates, cups, cutlery
use microwave in cooking
avoid using microwave in cooking
avoid Genetically Modified Foods/GMO
do not avoid Genetically Modified Foods
environmental allergies
Thyroid deficient/Hyper-Hypothyroid
take supplements regularly
drink tap water
drink purified water
take Aspirin/Acetaminophen
received X-Rays/MRI
taken Prescription drugs
Sodium Fluoride in toothpaste/drinking water
frequent cell phone user
work in front of computer
use conventional sunscreen
use conventional cleaning products ie.bleach, cleansers
avoid using conventional cleaning products
use perfume/cologne regularly
avoid using perfume/cologne
breast fed as child
bottle fed as child
bottle fed soy milk as child
Dietary/Health History of Participant Comments: 
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Family health history of Participant/ ie. susceptibility to disease, illness, vaccine related trauma, dietary issues in the family line & environmental factors (choose all corresponding options dating back two generations if applicable): 
meat eaters
vegetarians
semi-vegetarians
vegan
junk food diet
used Crisco regularly
used margarine regularly
dairy-rich diet
gluten-rich diet
used iodized salt regularly
access to farm food
relied on fast food
minimal exposure to sunlight
frequent exposure to sunlight
lived in vicinity of a power plant/factory
worked at factory/power plant
lived in vicinity of cell phone tower
parents work/worked with chemicals/heavy metals
grandparents work/worked with chemicals/heavy metals
lived in vicinity of a Military Installation/Base
worked at Military Installation/Base
lived in vicinity of a hospital
parent worked at hospital
mother consumed soy containing products during pregnancy
mother consumed aspartame containing products during pregnancy
mother used prescription drugs during pregnancy
mother used anti-depressant medication/drugs during pregnancy
mother smoked cigarettes regularly during pregnancy
mother consumed alcohol regularly during pregnancy
parent/grandparent prescribed anti-viral drugs
parent/grandparent prescribed anti-psychotic drugs
parent/grandparent prescribed anti-depressant drugs
parent/grandparent prescribed anxiolytic drugs
parent(s) exposed to radiation/chemical agents/toxic heavy metals in war
grandparent(s) exposed to radiation/chemical agents/toxic heavy metals in war
relied on contaminated water supply
parents are/were smokers
grandparents are/were smokers
parents have/had mercury amalgam fillings
grandparents have/had mercury amalgam fillings
parents were breast fed as children
parents were bottle fed as children
Gastroenteritis in family
Endometriosis in family
Narcolepsy in family
parent with Sub-Clinical Epileptic Seizures
parent with Grand Mal Epileptic Seizures
grandparent with Sub-Clinical Epileptic Seizures
grandparent with Grand Mal Epileptic Seizures
parents have/had ADD/ADHD
grandparents have/had ADD/ADHD
parents had Crones/Colitis
grandparents had Crones/Colitis
parent(s) had Inflammatory Bowel Disease
grandparent(s) had Inflammatory Bowel Disease
Cancer/Leukemia in family
Diabetes in family
Asthma in family
Alzheimer's Disease in family
Heart Disease in family
Parkinson's Disease in family
Celiac Disease in family
Lou Gerig's Disease/ALS in family
Lupus Disease in family
Mononucleosis in family
Chronic Fatigue Syndrome/Fybromyalgia in family
Chronic Bronchitis in family
Chronic Fatigue Syndrome in family
Febrile Convulsions in family
Anaphylaxis in family
Bacterial Pneumonia in family
Encephalitis in family
premature hair loss in family
chronic ear infections in family
anxiolytic medication/drugs taken during pregnancy
anti-depressant medication/drugs taken during pregnancy
anti-psychotic medication/drugs taken during pregnancy
chronic headaches in family
Tourette's Syndrome in family
alcoholism in family
parents have/had chronic & debilitating illness
grandparents have/had chronic & debilitating illness
parents received full schedule of standard vaccinations
parents received partial schedule of standard vaccinations
grandparents received full schedule of standard vaccinations
grandparents received partial schedule of standard vaccinations
food/environmental allergies in family
parents use/used Prescription drugs
grandparents use/used Prescription drugs
parents use/used Sodium Fluoride in toothpaste/drinking water
grandparents use/used Sodium Fluoride in toothpaste/drinking water
parents received X-Rays/MRI
grandparents received X-Rays/MRI
parents used microwave for cooking
grandparents used microwave for cooking
use/used conventional cleaning products ie.bleach, cleansers
avoid/avoided using conventional cleaning products
drink/drank from plastic containers
avoid/avoided drinking from plastic containers
use/used aluminum plates, cups, cutlery
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