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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