Full Name
Email
*
What age group are you in?
17 or below
18-29
30-44
45-59
60+
Gender
Male
Female
Prefer not to say
Have you been diagnosed with any of the following conditions
*
ADHD
Arthritis
Cancer
Crohn's Disease
Depression
Epilepsy
Fibromyalgia
Glaucoma
Inflammatory Bowel Disease
Insomnia
Irritable Bowel Syndrome (IBS)
Lupus
Migraines
Multiple Sclerosis (MS)
Parkinson's Disease
Post-Traumatic Stress Disorder (PTSD)
Tourette Syndrome
None of the Above
Other
If other, please specify
Do you suffer from any of these symptoms?
*
Pain
Stress
Anxiety
Muscle Spasms
Loss of Appetite
Depression
Insomnia
Menstrual Cramps
None
Other
If other, please specify
Are you taking pharmaceutical medication to treat any of the following symptoms or conditons listed previously?
*
Yes
No
History
Have you ever used marijuana
*
Yes
No
Do you currently use marijuana
*
Yes
No
Have you ever been addicted to any drugs or alcohol in the past?
*
Yes
No
Unsure
Health Questions
Do you suffer from any heart disease?
*
Yes
No
Unsure
Are you pregnant or trying to have children?
*
Yes
No
Unsure
Have you ever had a psychotic episode
*
Yes
No
Unsure
Do you have a family history with psychosis?
*
Yes
No
Unsure
Do you suffer from any serious liver, kidney, heart, or lung disease?
*
Yes
No
Unsure