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Patient Qualification
Take our easy qualification survey to see if you qualify for a Medical Marijuana recommendation today!
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Name
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First
Last
Phone
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Email
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Please select your medical condition
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Parkinson Disease
ALS
Crohn's disease
Multiple Sclerosis
HIV/ AIDS
Anxiety
Anorexia
Arthritis
Sickle Cell Anemia
Uncontrolled Seizures/ Epilepsy
Uncontrolled muscle spasms
PTSD
Cancer
Glaucoma
Cachexia (Wasting Syndrome)
Severe & Chronic Pain
Spasticity
A terminal illness diagnosed by another physician
Cyclical Vomiting Syndrome
Diabetes
Hepatitis C
Irritable Bowel Syndrome (with chronic abdominal pain)
Severe Nausea
My condition affects my everyday life
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Not at all
Half the time
All the time
I have constant pain from my condition
*
Not at all
Half the time
All the time
I can not do the things I enjoy because of my condition
*
Not at all
Half the time
All the time
I have been prescribed medications with the the possibility of addiction and or adverse side effects
*
Not at all
Half the time
All the time
I do not sleep well or at all because of my condition
*
Not at all
Half the time
All the time
My condition has impacted my relationship with friends and or loved ones
*
Not at all
Half the time
All the time
I have had to alter my life drastically because of my condition
*
Not at all
Half the time
All the time
If medical marijuana is able to help with my condition, It would make my quality of life much better
*
Not at all
Half the time
All the time
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