Welcome to Our Medicinal Cannabis Health Questionnaire

To help you determine if medicinal cannabis might be suitable for you, please complete the following health questionnaire. Your responses will assist us in providing personalized guidance and ensuring that you receive the most appropriate care and support. All information provided will be kept confidential.

1. Personal Information

Full Name:
Date of Birth:
Email Address:
Phone Number:
Address:
2. Medical History

Do you currently have a medical diagnosis or condition?

Yes
No
If yes, please specify:

List any chronic conditions or diseases you are currently managing:

Are you currently under the care of a physician or specialist?

Yes
No
If yes, please provide their name and contact information:

Have you previously used cannabis for medicinal purposes?

Yes
No
If yes, please describe your experience:

3. Symptoms and Conditions

Please indicate the symptoms or conditions you are seeking relief for:
(Check all that apply)

Chronic pain
Anxiety
Depression
Insomnia
Nausea
Appetite loss
Muscle spasms
Other (please specify):
On a scale of 1 to 10, how severe are your symptoms?
(1 = Minimal, 10 = Severe)

4. Current Medications and Treatments

List any medications you are currently taking, including over-the-counter and prescription:

Do you have any known allergies to medications or substances?

Yes
No
If yes, please specify:

Have you had any adverse reactions to cannabis or cannabis-based products in the past?

Yes
No
If yes, please describe:

5. Lifestyle and Preferences

Are you interested in learning about methods of consuming cannabis (e.g., smoking, vaping, edibles, tinctures)?

Yes
No
Do you have any preferences or concerns regarding the form of cannabis you would like to use?
(e.g., THC vs. CBD, specific strains)

Do you have access to a suitable space for growing cannabis if you choose to cultivate it yourself?

Yes
No
6. Legal and Compliance

Are you aware of the legal regulations surrounding medicinal cannabis use and cultivation in your area?

Yes
No
Are you willing to comply with local regulations and guidelines regarding medicinal cannabis?

Yes
No
7. Additional Information

Please provide any additional information or specific concerns you have about using medicinal cannabis:
Consent and Acknowledgment

By completing this questionnaire, you consent to our use of the information provided to assess your suitability for medicinal cannabis. Your data will be handled confidentially in accordance with privacy regulations.

Signature: Date:

Thank you for completing the questionnaire. A representative will review your responses and contact you with further information on next steps.