Is CBD Right For Me? Self-Assessment Form
Complete this self-assessment to help determine if CBD may be suitable for your needs. This form is for informational purposes only and does not guarantee a prescription.
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
What symptoms are you hoping CBD may help with?
*
Pain
Anxiety
Sleep
Inflammation
Migraines
Mood
Other
Do you have any of the following medical conditions? (Select all that apply)
*
Liver disease
History of psychosis
Bipolar disorder
Significant heart condition
Pregnant or breastfeeding
None of the above
Please list your current medications
What are your goals for treatment?
Declaration: This form does not guarantee a prescription. Prescribing decisions are made by a registered medical practitioner following assessment.
Signature
*
Date Signed
*
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Month
-
Day
Year
Date
Submit Self-Assessment
Submit Self-Assessment
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