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Allergies:

Diagnosis or condition: (Select all that apply)

CancerHIV / AIDSAmyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)Parkinson’s DiseaseMultiple SclerosisSpinal Cord Damage Causing SpasticityEpilepsyInflammatory Bowel DiseaseNeuropathiesHuntington’s DiseaseChronic Pain

Associated complicating conditions: (Select all that apply)

Cachexia or wasting syndromeSevere or chronic painSevere nauseaSeizuresSevere or persistent muscle spasms

What are you hoping to achieve through cannabis therapy?
What if any concerns would you like us to address?

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