Study Referral Form - Wadsworth Center
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1
2NYSDOH Epidiolex® Expanded Access for
Treatment Resistant Epilepsy
Study Referral Form
GENERAL
P ATIENT
I NFORMATION
Date of Request: _____/_____/_____ DOB: _____/_____/_____ Age: __________ Gender: Male ¨ Female ¨
Patient S.S. # (Last 4 digits):__________
Parent/Guardian name: _______________________________
Patient Name: ______________________________
Address: ___________________________________
Address (if different):_________________________________
__________________________________________
_________________________________
Primary Phone #:_______________________ Secondary Phone #:_______________________
REFERRING
P HYSICIAN
C ONTACT
I NFORMATION
Referring Physician: ______________________________________
Email:
Address: __________________________________________________________________________________________
Phone Number: __________________ FAX: __________________
License #:______________________________
PATIENT
E LIGIBILITY
Q UESTIONS
F OR
R EFERRING
P HYSICIAN
Diagnosis: _________________________________________________________________________
Number of countable seizures*: _____________/week
_____________/month
*non-countable includes absence and myoclonic (see appendix B)
Does this patient meet all of the Inclusion Criteria and none of the Exclusion Criteria in appendix C?
YES o NO o
Is this patient eligible for a GW Pharmaceutical Randomized Controlled Trial?
YES o NO o
Is an electroencephalographic (EEG) video monitoring report documenting a typical seizure attached?
YES o NO o
(Such a report is required for submission with this form, a video showing a typical seizure is required upon request)
YES
NO
Has this patient been on stable levels of 1-4 Antiepileptic Drugs (AEDs) for a minimum of 4 weeks?
List the name and dose of each AED:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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