CelWel - Autism Health

Participant (Child) Information

1. Child’s Full Name(Required)

2. Date of Birth / Age:(Required)

3. Weight (lbs or kg):(Required)

4. Gender:(Required)

5. Autism Diagnosis(Required)

Level of Autism

Additional diagnoses (if any):

6. Current Symptoms (check all that apply):(Required)

Inflammation / joint pain

Immune-related symptoms

Digestive issues

Fatigue

Behavioral symptoms (e.g., irritability, aggression, rigidity)

Neurological symptoms (e.g., sensory issues, tics, brain fog)

Sleep disturbances

Other (describe):

Parent / Guardian Information

7. Parent / Guardian #1 Name:(Required)

8. Parent / Guardian #2 Name (if applicable):(Required)

9. Relationship to Child:(Required)

10. Email Address:(Required)

11. Contact Number:(Required)

Health & Eligibility Questions

12. Does the child have allergies to herbal products or any supplement ingredients?(Required)

Yes

If yes, please list:(Required)

13. Does the child have any food or drug sensitivities?(Required)

Yes

If yes, please list:(Required)

14. Emergency Contact Name:(Required)

15. Emergency Contact Phone:(Required)

Study Participation Details

CelWel™ is an herbal supplement designed to support healthy immune function and reduce inflammation. Ingredient list available at: https://celwel.com/pages/ingredients

16. Please describe your goals or expectations for this study:(Required)

17. Are there any additional medical conditions or concerns not listed above?(Required)

Recommended Dosing Guidelines (For Parent Reference)

Clark’s Rule Dosage Guidelines: We follow Clark’s Rule, which bases dosage on the child’s weight relative to a 150 lb adult dose. Children or teens weighing 100 to 150 lbs receive the full adult dose, those weighing 75 to 100 lbs receive two thirds of the adult dose, and those weighing 75 lbs or less receive one half of the adult dose, with adjustments as appropriate. Frequency Recommendation: Use as suggested on the label. However, in cases where strict compliance is difficult, dosing throughout the day has still shown benefit. For example, one parent administered six doses on day one and three doses per day thereafter, and improvements were still observed. These guidelines are provided for parent reference to help adjust dosing safely based on weight and compliance.

Participant / Parent Agreement

1. I agree to participate in the 3-week CelWel Herbal Supplement Study and will do my best to follow the study guidelines.(Required)

I Agree

I Disagree

2. I understand that participation is voluntary, and I may reach out to the study team at any time with questions.(Required)

I Agree

I Disagree

3. I understand that upon successful completion of the study, I will receive one additional free box of CelWel.(Required)

I Agree

I Disagree

Medical Disclaimer

CelWel is a dietary herbal supplement. These statements have not been evaluated by the U.S. Food and Drug Administration (FDA). This supplement is not intended to diagnose, treat, cure, or prevent any disease. Participation in this study does not replace medical care. Parents/guardians acknowledge responsibility for consulting their child’s healthcare professional regarding medical conditions, medications, or supplement use.

CelWel 3-Week Independent Study Enrollment Form

Participant (Child) Information

Parent / Guardian Information

Health & Eligibility Questions

Study Participation Details

Recommended Dosing Guidelines (For Parent Reference)

Participant / Parent Agreement

Medical Disclaimer