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2015
March
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Current weight
Any change in your oil supplier or in the concentration of the current oil?
What is the current dose of oil in ml per dose?
How many doses do you give per day?
List any negative side effects of the oil:
Any changes in prescription medication in the last month?
Any change in supplements or alternative treatments?
Ketogenic diet?
Yes
No
If the patient has had an EEG in the past month, what did it show?
What is the current frequency of seizures?
Daily
Weekly
Monthly
Other
Please approximate the overall percentage reduction in
number of seizures
since starting CBD oil:
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please approximate the percentage reduction of
severity or intensity of seizures
since starting CBD oil:
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please describe overall changes in
how long seizures last
since starting CBD oil:
Unchanged
Seizures are overall shorter
Seizures are overall longer
Other
Please describe
time to recover
from seizures since starting CBD oil:
Unchanged
Shorter recovery time
Longer recovery time
Other
Please report effect of CBD on appetite:
Unchanged
Increased appetite
Decreased appetite
Other
Please report effect of CBD oil on sleep:
Unchanged
Improved sleep
Worsened sleep
Other
Please describe effect of CBD oil on mood:
Unchanged
Improved mood
Worsened mood
Other
Describe any change in development or response to therapy
Describe any other changes that you attribute to CBD oil treatment
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