The
  Ketogenic
Resource


Questionnaire  

 

 

This questionnaire is intended specifically for people who have used the ketogenic diet in the UK.

One purpose of this questionnaire is to identify as many people in the UK as possible that have experience of the ketogenic diet so that, in the future it may be possible to build support groups and other services. The other purpose is to establish the level of medical activity with the diet in the UK.

If you know of someone else who has experience of the ketogenic diet in the UK, please tell them about this questionnaire, and ask them to consider completing it.

All individual information obtained from this questionnaire will be treated as confidential. The information will only be used for the purpose of promoting the ketogenic diet. We reserve the right to publish statistical information derived from the questionnaire, but only for the purpose of promoting the ketogenic diet. No information from individual responses will be made available to third parties without the express consent (written or electronic) of the respondent.

If you are using Internet Explorer version 3 then   click here  

Contact information

.

Your name and postal address

Your telephone number

Your e-mail address

Keto kid information

Name of the keto person

Sex

Date of birth

Date diet started

Date diet ended (if relevant)

 .

Male Female
Type of diet Classical
MCT oil
Radcliffe
Great Ormond Street
Other
Not known
Hospital information

Name of the hospital

Name of the neurologist responsible

Name of the dietician responsible

 .
Outcome of the diet Too early to tell

Completely successful
(fits were reduced substantially, or eliminated)
Successful
(fits were reduced by 50% or more)
Partially successful
(fits were reduced, but by less than 50%)
Unsuccessful
(no useful reduction in fits, or increase)
Diet abandoned
(eg because of feeding difficulties)
Contact list

May we add this information
to our contact list

 .

Yes No
Comments

Please comment on your assessment of the diet and the reasons for the outcome, particularly if the diet was less than successful.

When you have completed the questionnaire, press the button:

return to   The Ketogenic Centre

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is the Internet Explorer version 3 questionnaire; there appears to be a format incompatibility between Internet Explorer version 3 and Netscape version 3 or 4 or Internet Explorer version 4

Contact information

.

Your name and postal address

Your telephone number

Your e-mail address

Keto kid information

Name of the keto person

Sex

Date of birth

Date diet started

Date diet ended (if relevant)

 .

Male Female
Type of diet Classical
MCT oil
Radcliffe
Great Ormond Street
Other
Not known
Hospital information

Name of the hospital

Name of the neurologist responsible

Name of the dietician responsible

 .
Outcome of the diet Too early to tell
Completely successful
(fits were reduced substantially, or eliminated)
Successful
(fits were reduced by 50% or more)
Partially successful
(fits were reduced, but by less than 50%)
Unsuccessful
(no useful reduction in fits, or increase)
Diet abandoned
(eg because of feeding difficulties)
Contact list

May we add this information
to our contact list

 .

Yes No
Comments

Please comment on your assessment of the diet and the reasons for the outcome, particularly if the diet was less than successful.

When you have completed the questionnaire, press the button:

return to   The Ketogenic Centre

 

 

(checked: )
(update 1.1: 18 July 2002)
(issue 1: 9 September 1997)