101 CBD – New Client Questionnaire Follow-Up

Date / Time

Date

Time

Name *

First

Last

Phone

Email *

What 101 CBD product(s) did you use? (please select Brand and Strength for the oils)

Alleviate
Chill
Boost
CBD Oil (no added herbs)
Pet CBD
300 mg Strength
600 mg Strength
1200 mg Strength
2400 mg Strength
Raw Relief Topical
Raw Renew Skin Treatment
Raw Relief Roll-On
Massage Oils

How long have you been using it?

2-4 weeks
4-6 weeks
6-8 weeks
8+ weeks

Describe how you are using it

How many times per day are you taking our CBD?

Less than once per day (eg. every other day)
1
2
3
4
5+

What dose are you taking each time?

Under 10mg (less than 1/2 dropper of 600mg)
10mg (1/2 dropper of 600mg)
20mg (1 full dropper of 600mg)
over 20mg

If over 20mg, how much are you taking?

How long are you leaving it under tongue?

Under 1 minute
1-3 minutes
3-5 minutes
5-7 minutes
Over 7 minutes

What issues did the product help with? (please check all that apply)

General wellness
Pain
Inflammation
Nerve issues
Anxiety/Stress
Insomnia
Mood
Brain Focus
Skin Health
Addiction Recovery
Tumor/Growth
Brain Focus
Lupus
Arthritis
Fibromyalgia
MS
Psoriasis
Eczema
Alzheimer’s
Autism
Seizures
Parkinson’s
Neuropathy
Nausea
Athletic Endurance
Athletic Recovery
Meditation

What improvements have you noticed?

What is your level of pain/anxiety/insomnia compared to when you first came in? (1 is lowest, 10 is highest)

Now that you've been taking our product for 6+ weeks, how has your ailment impacted daily living regarding SELF CARE? (0 Lowest Amount of Impact, 4 Highest Amount of Impact)

Now that you've been taking our product for 6+ weeks, how has your ailment impacted daily living regarding WORK? (0 Lowest Amount of Impact, 4 Highest Amount of Impact)

Now that you've been taking our product for 6+ weeks, how has your ailment impacted daily living regarding SOCIALIZING? (0 Lowest Amount of Impact, 4 Highest Amount of Impact)

Now that you've been taking our product for 6+ weeks, how has your ailment impacted daily living regarding COMMUNITY ACCESS? (0 Lowest Amount of Impact, 4 Highest Amount of Impact)

Now that you've been taking our product for 6+ weeks, how has your ailment impacted daily living regarding SLEEP? (0 Lowest Amount of Impact, 4 Highest Amount of Impact)

Now that you've been taking our product for 6+ weeks, how has your ailment impacted daily living regarding EXERCISE? (0 Lowest Amount of Impact, 4 Highest Amount of Impact)

Now that you've been taking our product for 6+ weeks, how has your ailment impacted daily living regarding MOOD? (0 Lowest Amount of Impact, 4 Highest Amount of Impact)

Comments on how our CBD has/has not improved your daily life.

Changes in number of medications and dosages after CBD use