OMMP Patient Profile

Patient Profile
Name*
E-mail
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Please fill this form out with as much information that you would like to share with the M91 Joint Committee.
Are you the parent of a pediatric patient?

yesno
How long have you been a patient with OMMP?*
Select Age Range

-2122-3233-4344-5455-6566+
Indicate your qualifying condition(s)

cancerglaucomaAgitation due to Alzheimer’sHIV AIDSPTSDCachexiaSevere PainSevere NauseaEpilepsyADDAutisimMuscle Spasms
How long have you been suffering? Was there a specific cause of the condition IE; accident, trauma, and exposure?
Prior to your cannabis prescription, what other courses of treatment did you try?
Do you use cannabis in conjunction with other treatments?
Can you describe improvements in your conditions through the use of cannabis?
If you are NOT your own grower: does your grower grow particular strains that aid in the treatment of your specific condition?

YesNo
Click the ways your grower helps you

Grows special strainsMaking concentrates / salvesDelivering medicineOther
Any additional ways?
Would you care to describe how, where and in what conditions you prefer your medicine to be grown in?
Any additional comments?
We intend to submit your profile to the legislators responsible for implementation of M91 and securing the future of OMMP. Feel free to share as much or as little personal information. We will respect your privacy and not share your details outside of this purpose.

Please feel free to attach additional pages. Completed forms are needed ASAP. Can also be filled out online at: Oregonsungrown.org. Hard copies can be mailed to PO Box 431 Williams, OR 97544 or scanned and emailed to info@oregonsungrown.org

If you have any problem with this form, please email info@oregonsungrown.org.
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Patient Profile

Please fill this form out with as much information that you would like to share with the M91 Joint Committee.