HOPE TINCTURES: AUTISM DOSING SURVEY

Dosing Guide Survey- HOPE(TM)

Thank you for taking the time to participate in our surveys to help improve treatment for individuals diagnosed with autism. We appreciate your time and participation.

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* 1. Website Legal Disclaimer and Terms of Use: This website is meant for informational purposes only and is not intended to take the place of consultation with your physician. This site is not a substitute for medical advice, diagnosis or treatment, nor is the information provided herein intended to replace consultation with a qualified physician. Disclaimer (Notice to Survey Respondents): The Originator of this survey is solely responsible for its contents. Your response to the survey is voluntary. If you are asked in the survey to reveal your identity or the identity of the organization on whose behalf you are responding and do not wish to do so, please do not respond to the survey. Your response will be used by the survey Originator only for the purpose identified by the Originator. Survey Originator cannot guarantee that access to such data will be kept confidential and secure. You therefore agree that any information or materials that you, or individuals acting on your behalf, provide to Survey Originator in your survey response will not be considered confidential or proprietary and that HG cannot and will not be held responsible to protect such data if you were to include it in your responses. Survey Originator will not be liable for any damages of any kind arising from this survey, including, but not limited to direct, indirect, incidental, punitive, and consequential damages. Survey Originator reserves the right to terminate or withdraw a survey, and your opportunity to participate in a survey, at any time and for any reason. Survey Originator alone has the right to view and use the survey results and may choose in its sole discretion not to disclose the survey results to you. We may contact you in the future for research purposes.

I have read the Survey Disclaimer and Agree to terms to proceed.

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* 2. Where did you learn about HOPE?

Physician

Word of Mouth/ Other Patients and Parents

Pharmacy/ Dispensary

Social Media

In the Press

Other (please specify)

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* 3. Does the patient have a diagnosis of autism?

Yes

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* 4. If Yes, Please specify where on the spectrum the patient falls

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* 5. What is the age of the patient? 

2-6 years

7-12 years

13-17 years

18-24

25+

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* 6. What is the sex of the patient?

Female

Male

Other or Prefer not to say

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* 7. How much does the patient weigh in pounds (if known)

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* 8. Are you the patient or the caregiver of a patient using HOPE? 

 

Patient

Caregiver

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* 9. Which medication is the patient using? 

HOPE 1

HOPE 2

BOTH

OTHER

Other (please specify)

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* 10. What date did the patient first start HOPE? 

Date / Time

Date

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* 11. Please check all symptoms you are looking to treat with HOPE

Anxiety

Communication Challenges

Focus and Attention

Insomnia

Irritability

Meltdowns

Self-Stimulatory Behaviors

Self-Injurious Behaviors

Overall behavioral wellness

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* 12. What was the patient's starting dose?

.25 ml

.5 ml

.75 ml

1 ml

1.5 ml

1.75 ml

2 ml +

IF YOU ARE USING MORE THAN ONE PRODUCT (please specify here):

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* 13. What is the patient's average effective dose?

.25 ml

.5 ml

.75 ml

1 ml

1.5 ml

1.75 ml

2 ml +

IF YOU ARE USING MORE THAN ONE PRODUCT (please specify here):

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* 14. How many doses per day does the patient receive?

1x on the morning

1x in the afternoon/ before bed

As needed

2x times per day

3x times per day

4x times per day

5+ times per day

IF YOU ARE USING MORE THAN ONE PRODUCT (please specify here):

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* 15. Are you satisfied with the overall results?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

HOPE TINCTURES: AUTISM DOSING SURVEY

Dosing Guide Survey- HOPE(TM)

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* 2. Where did you learn about HOPE?

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* 3. Does the patient have a diagnosis of autism?

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* 4. If Yes, Please specify where on the spectrum the patient falls

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* 5. What is the age of the patient?

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* 6. What is the sex of the patient?

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* 7. How much does the patient weigh in pounds (if known)

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* 8. Are you the patient or the caregiver of a patient using HOPE?

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* 9. Which medication is the patient using?

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* 10. What date did the patient first start HOPE?

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* 11. Please check all symptoms you are looking to treat with HOPE

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* 12. What was the patient's starting dose?

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* 13. What is the patient's average effective dose?

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* 14. How many doses per day does the patient receive?

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* 15. Are you satisfied with the overall results?

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* 16. Please briefly describe your/your child’s experience with HOPE products including benefits and/ or side-effects

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* 17. If you would like to receive updates and future surveys please enter your email here