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. OK Question Title * 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. OK Question Title * 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) OK Question Title * 3. Does the patient have a diagnosis of autism? Yes No OK Question Title * 4. If Yes, Please specify where on the spectrum the patient falls Severe Moderate to Severe Moderate Moderate to Mild Mild High Functioning or Asperger's OK Question Title * 5. What is the age of the patient? 2-6 years 7-12 years 13-17 years 18-24 25+ OK Question Title * 6. What is the sex of the patient? Female Male Other or Prefer not to say OK Question Title * 7. How much does the patient weigh in pounds (if known) OK Question Title * 8. Are you the patient or the caregiver of a patient using HOPE? Patient Caregiver OK Question Title * 9. Which medication is the patient using? HOPE 1 HOPE 2 BOTH OTHER Other (please specify) OK Question Title * 10. What date did the patient first start HOPE? Date / Time Date OK Question Title * 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 OK Question Title * 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): OK Question Title * 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): OK Question Title * 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): OK Question Title * 15. Are you satisfied with the overall results? Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied OK Question Title * 16. Please briefly describe your/your child’s experience with HOPE products including benefits and/ or side-effects OK Question Title * 17. If you would like to receive updates and future surveys please enter your email here OK DONE
