CBD Pre-Consult Medical Questionnaire

CBD Pre-Consult Medical Questionnaire

Please complete this form to provide your medical history and consent prior to your CBD consultation.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
GP Name (if applicable)
Presenting Concern
Describe your main symptoms and how they impact your daily life
Past Medical History (select all that apply)

Other
Current Medications (including supplements)
Lifestyle Information

Please provide details about your lifestyle.
Alcohol intake
Example: None, Occasional, Daily
Smoking/Vaping
Example: None, Occasional, Daily
Signature
Date of Consent

MonthDayYear
Date
Should be Empty: