'Autism : Real Food Heals' Seminar on 28/09/14

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Thank you for your interest in joining our seminar. Please use this form to register for the event. All info provided in the questionnaire will be kept anonymous.

Sunday (Ahad), 28 September 2014

Time (Waktu): 11.00am - 1.30pm

Venue (Lokasi): Moms & Tots Shoppe, 3A-2, Jalan PPS 1, Pusat Perdagangan Selaseh, Batu Caves (https://www.facebook.com/MomNTotsShoppe)

Fee (Yuran): RM50 for individuals (perseorangan) / RM80 for couples (suami & isteri). Payable on event day (Bayar para hari kursus)

All participants will receive printed notes & access to an exclusive Facebook Group for continued support and access to new information. (Setiap peserta diberi nota & akses kepada FB Group khas)

Number of participants: Maximum 30 participants only. (Terhad kepada 30 peserta sahaja)

English & Bahasa Malaysia akan digunakan dalam seminar ini.

Name (Nama)

Contact Number (Nombor Telefon)

No. of Participants (Bilangan Peserta)

How old is your child? (Berapa usia anak anda?)

What's your child's gender? (Apakah jantina anak anda?)

Male (Lelaki)

Female (Perempuan)

Clear selection

What is your child's blood type? (Apakah jenis darah anak anda?)

Clear selection

How was your child born? (Bagaimanakah anak anda dilahirkan?)

Natural Birth without any medical interventions

Natural Birth with Epidural / Induced / etc

Caesarean (C-Section)

Clear selection

Was your child fed Formula Milk or Breast Milk up to 2 years old? (Sehingga umur 2 tahun, apakah sumber susu utamanya, Susu Formula atau Susu Ibu?)

Exclusive Breast Milk (Susu Ibu)

Mixed (Campur)

Exclusive Formula Milk

Clear selection

Roughly how many times has your child been given Antibiotics? (Lebih kurang berapa kali anak anda telah diberi Antibiotik?)

None (Tiada)

1 - 3

> 4

Clear selection

Please list up to 5 foods/beverages your child must eat everyday. If fewer than 5, list all of them. (Nyatakan sehingga 5 makanan/minuman yang anak anda makan tiap-tiap hari). Jika kurang dari 5, nyatakan semuanya.

Contoh: Roti Putih, Biskut, Fresh Milk, Spaghetti, Milo

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