Dr. Woeller China Autism Health Questionnaire (Follow-Up)
沃勒医生中国咨询问卷（复诊）
Please keep your explanations brief and concise. This is helpful for a more thorough review.Also, if a question isn’t known or isn’t relevant than leave it blank.
请您用简明扼要的语言回答下列问题。这对全面诊断十分关键。同时，如果您觉得有些问题与病情无关，请不要填写。
病人订单号（特殊儿童一点通）（order num）: ________________________________
病人Email地址：
病人姓名（Name of patient）: __________________________________________________________
病人年龄（Age of patient）: _____________________
病人出生年月（月/年 DOB: mm/yy）: _________________________
病人体重（Weight of patient）: ___________________
孩子是否能吞服胶囊或药片（Can child swallow capsules or tablets） ___是 Yes ___否 No
Allergies to medications or supplements:
是否对药物或营养补充剂过敏？
Current Medications and/or supplements:
目前正在使用的药物或补充剂：
Medical Problems(allergies, ear infections, heart, lungs, digestive issues, etc.):
病症信息（过敏、耳部感染、心肺问题或消化道问题等）：
Digestion Concerns(constipation, diarrhea, foul gas):
消化道问题（便秘、腹泻或放臭屁等）：
Is Child Currently On Special Diet (Ex: Gluten/Casein Free)?
孩子是否在进行特殊饮食（比如麦蛋白和乳蛋白禁食—无麦无奶禁食）？
What Positive Changes Have Occurred From Various Therapies (Ex: Better eye contact, improved sleep, playing more appropriately, less behavior problems, improved language)
在上次咨询后症状有了哪些改善？（比如：眼神交流多了、睡眠改善、更喜欢游戏、行为问题减少或言语词汇量变多，大便，肠胃）
· Diet Changes (what positive things are happening?)
饮食改变（采取禁食后出现了哪些改善？）
· Supplements(which supplements are having a positive effect and what is happeningexactly?)
补充剂（哪些补充剂有效？出现了哪些改善？）
· Medications(which medications, if currently taking, are having a positive influenceand what is happening exactly?)
药物（指处方药，目前服用的哪些药物有效果？出现了哪些改善？）
主要问题（Main Concerns）:
· Language (what language deficits exist – if any - explain)
语言（主要存在哪种语言问题——如果有，请说明）
· Social (is child interested in other children, does the child play appropriately, does your child lack any interest in being social - explain):
交流（孩子会与其他孩子互动吗？孩子会玩游戏吗？孩子是否对与人交流有兴趣？——请说明）
· Behavior (Is your child aggressive towards other, self-abusive, i.e. hitting self,head-banging, is your child easily upset or emotional – explain):
行为（您的孩子是否存对他人存在攻击性行为、自我伤害，比如打自己或者敲自己的头等？您的孩子是否存在情绪波动过大的情形？——请说明）
· Anxiety and Obsessive Compulsive Behavior (does your child exhibit anxiety in social situations, generalized anxiety overall, ritualistic behavior or repetitive behavior - explain):
焦虑与强迫行为（您的孩子是否在交流过程中出现紧张情绪？或者是时刻处于紧张状态？孩子是否存在刻板或强迫行为？——请说明）
· Self-stimulatory Behavior (does your child have self-stimulatory behavior, i.e. hand-flap,look out of corner of eye, spin, shake fingers - explain):
自我刺激行为（您的孩子是否会自我刺激，比如拍手、斜眼看东西、原地转圈或晃动手指等？——请说明）
· Sleeping Problems (does your child have sleeping issues, difficulty falling asleep,waking up frequently during the night, etc. – explain)
睡眠问题（您的孩子是否存在睡眠问题，比如难以入睡或夜间经常惊醒等？——请说明）
