Patient Information

* First Name :
* Last Name :

* What is your date of birth of patient?

Month	Day	Year

* Date of survey?

Month	Day	Year

* Please list all diagnoses:

* Current prescription medications?

* Current supplements or alternative treatments?

* Please approximate how many medications the patient has tried for seizures prior to starting CBD oil:

* Ketogenic diet?

Yes

No

* Does the patient have a vagal nerve stimulator (VNS)?

Yes

No

* Current weight?

* Person filling out survey and relation to patient?

* Date that patient started CBD oil?

Month	Day	Year

* Name of current supplier of CBD oil?

* How many mg of CBD in 1 mL in the current oil? (It should be on the label)

* How many mg of THC in 1 mL in the current oil? (It should be on the label)

* Type of oil?

coconut oil

olive oil

Other

* What is the current dose of CBD oil in ml (for one dose)?

* How many times per day does the patient take the oil?

* Does the patient take THCA oil?

Yes

No

* Does the patient take high THC oil?

Yes

No

If the patient takes THCA or THC oil, please note the dose in mg or ml of the oil or oils:

Date of last EEG?

Month	Day	Year