Forms & Feedback

Am I a Candidate?

By telling us a little more about you and your condition, we can tell if you would be a candidate for regenerative treatments. Knowing more about the background of your condition will help us give you the most accurate information.

Leave a Google Review

We value your feedback and would appreciate your taking a moment to share your experience with us and others by writing a Google review. If you have already written one, you should still submit another with updates on your treatment progress and ongoing experiences with us.

Rate Your Experience

While we really appreciate leaving a Google review, this short survey is designed to rate your experience of a specific procedure. You may complete this for as many visits as you would like.

New Patient Registration Forms

The New Patient Registration Forms are fillable. You may choose to:

Complete in Adobe, save them, then email to svisser@fdtcenter.com
Print and bring them with you to your visit
Complete the forms in our office upon arrival

Pre-Treatment Survey

The Pre-Treatment Survey assess your symptoms and condition prior to treatment. This allows us to monitor your progress and tailor your care.

Treatment Progress

The short Treatment Progress survey help us evaluate your response to treatment. Your feedback helps us to track outcomes and continue providing the highest standard of care.

ATEC (for Autism Treatment)

The ATEC (Autism Treatment Evaluation Checklist) helps us evaluate response to treatment. Your feedback helps us to track outcomes and continue providing the highest standard of care.

ATEC (Autism Treatment Evaluation Checklist)

Patient's first name

Patient's last name

Person completing this form (name and relation to patient)

Patient's date of birth

Month

Day

Year

Today's date

I. Speech/ Language/ Communication

1. Knows own name

Not true (2)

Somewhat true (1)

Very true (0)

2. Responds to ‘No’ or ‘Stop’

Not true (2)

Somewhat true (1)

Very true (0)

3. Can follow some commands

Not true (2)

Somewhat true (1)

Very true (0)

4. Can use one word at a time (No, Eat, Water, etc.)

Not true (2)

Somewhat true (1)

Very true (0)

5. Can use 2 words at a time (Don't want, Go home, Want juice, etc.)

Not true (2)

Somewhat true (1)

Very true (0)

6. Can use 3 words at a time (Want more milk)

Not true (2)

Somewhat true (1)

Very true (0)

7. Knows 10 or more words

Not true (2)

Somewhat true (1)

Very true (0)

8. Can use sentences with 4 or more words

Not true (2)

Somewhat true (1)

Very true (0)

9. Explains what he/she wants

Not true (2)

Somewhat true (1)

Very true (0)

10. Asks meaningful questions

Not true (2)

Somewhat true (1)

Very true (0)

11. Speech tends to be meaningful/relevant

Not true (2)

Somewhat true (1)

Very true (0)

12. Carries on fairly good conversation

Not true (2)

Somewhat true (1)

Very true (0)

13. Has normal ability to communicate for his/her age

Not true (2)

Somewhat true (1)

Very true (0)

II. Sociability

1. Seems to be in a shell – can not be reached

Not true (0)

Somewhat true (1)

Very true (2)

2. Ignores other people

Not true (0)

Somewhat true (1)

Very true (2)

3. Pays little or no attention when addressed

Not true (0)

Somewhat true (1)

Very true (2)

4. Uncooperative and resistant

Not true (0)

Somewhat true (1)

Very true (2)

5. No eye contact

Not true (0)

Somewhat true (1)

Very true (2)

6. Prefers to be left alone

Not true (0)

Somewhat true (1)

Very true (2)

7. Shows no affection

Not true (0)

Somewhat true (1)

Very true (2)

8. Fails to greet parents

Not true (0)

Somewhat true (1)

Very true (2)

9. Avoids contact with others

Not true (0)

Somewhat true (1)

Very true (2)

10. Does not imitate

Not true (0)

Somewhat true (1)

Very true (2)

11. Dislikes being held/cuddled

Not true (0)

Somewhat true (1)

Very true (2)

12. Does not share or show

Not true (0)

Somewhat true (1)

Very true (2)

13. Does not wave ‘bye bye’

Not true (0)

Somewhat true (1)

Very true (2)

14. Disagreeable/not compliant

Not true (0)

Somewhat true (1)

Very true (2)

15. Temper tantrums

Not true (0)

Somewhat true (1)

Very true (2)

16. Lacks friends/companions

Not true (0)

Somewhat true (1)

Very true (2)

17. Rarely smiles

Not true (0)

Somewhat true (1)

Very true (2)

18. Insensitive to other's feelings

Not true (0)

Somewhat true (1)

Very true (2)

19. Indifferent to being liked

Not true (0)

Somewhat true (1)

Very true (2)

20. Indifferent if parent(s) leave

Not true (0)

Somewhat true (1)

Very true (2)

III. Sensory/ Cognitive Awareness

1. Responds to own name

Not true (2)

Somewhat true (1)

Very true (0)

2. Responds to praise

Not true (2)

Somewhat true (1)

Very true (0)

3. Looks at people and animals

Not true (2)

Somewhat true (1)

Very true (0)

4. Looks at pictures (and T.V.)

Not true (2)

Somewhat true (1)

Very true (0)

5. Does drawing, coloring, art

Not true (2)

Somewhat true (1)

Very true (0)

6. Plays with toys appropriately

Not true (2)

Somewhat true (1)

Very true (0)

7. Appropriate facial expression

Not true (2)

Somewhat true (1)

Very true (0)

8. Understands explanations

Not true (2)

Somewhat true (1)

Very true (0)

9. Aware of environment

Not true (2)

Somewhat true (1)

Very true (0)

10. Aware of danger

Not true (2)

Somewhat true (1)

Very true (0)

11. Shows imagination

Not true (2)

Somewhat true (1)

Very true (0)

12. Initiates activities

Not true (2)

Somewhat true (1)

Very true (0)

13. Dresses self

Not true (2)

Somewhat true (1)

Very true (0)

14. Curious, interested

Not true (2)

Somewhat true (1)

Very true (0)

15. Venturesome - explores

Not true (2)

Somewhat true (1)

Very true (0)

16. “Tuned in” — Not spacey

Not true (2)

Somewhat true (1)

Very true (0)

17. Looks where others are looking

Not true (2)

Somewhat true (1)

Very true (0)

IV. Health/ Physical/ Behavior

1. Bed-wetting

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

2. Wets pants/ diapers

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

3. Soils pants/diapers

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

4. Sleep problems

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

5. Extremely limited diet

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

6. Hyperactive

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

7. Lethargic

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

8. Hits or injures self or others

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

9. Sound-sensitive

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

10. Destructive

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

11. Anxious/ fearful

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

12. Unhappy/ cries often

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

13. Obsessive speech

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

14. Rigid routine

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

15. Shouts or screams

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

16. Demands sameness

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

17. Often agitated

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

18. Fixated on certain objects/ topics

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)

19. Repetitive movements (stimming, rocking, etc)

Not a problem (0)

Minor problem (1)

Moderate problem (2)

Serious problem (3)