Name *

Address *

Phone Number *

Birthdate *

Email *

Do you have any allergies *

If yes please describe what they are *

What are the symptoms that you are suffering from that you feel marijuana will help you with. *

Have you been seen by a physician for these symptoms *

If so what physician *

How long ago *

At what Hospital *

Do you currently suffer from any other medical conditon *

Please list any conditions and any medications used to treat it *

Are you currently taking any narcotics *

If yes please describe what, how much and how often *

Do you have any history of anxiety or mental illness *

Have you used marijuana before *

Did it help with any of the above listed conditions *

If you are a female, are you currently pregnant *

Are you currently on probation or parole *

Have you ever been convicted of a drug related felony *