Cannabis Patient Self-Questionnaire

Cannabis Patient Self-Questionnaire

You may be struggling with the idea if you need a cannabis nurse consultation. Please answer the questions below.These will guide you to determine if a consultation would be helpful to you on the best path to medical cannabis use.
Name *

First Name Last Name
Email *
example@example.com
Street Address
City *
State *
Zip Code
Phone Number

Area Code Phone Number
I would like to pursue an individualized approach to optimize my health & wellness.

Yes No
I have pain that I would like to control without opioids.

Yes No
I have generalized aches and pains.

Yes No
I am currently taking pharmaceuticals or would like toreduce my pharma intake.

Yes No
I’m seeking cannabis for a child or adolescent patient.

Yes No
I have been diagnosed with cancer.

Yes No
I’m seeking cannabis to manage/improve a chronic or complex medical condition.

Yes No
Have you ever been diagnosed with a mental healthcondition?

Yes No
Have you ever suffered from a respiratory illness?

Yes No
Are you on any pharmaceutical medications?

Yes No
If you answered “Yes” to any of the above questions, seeking a nurse
consultation is important to ensure safe and optimal medical cannabis use. If your concern was not addressed above, but you are still unsure, you can schedule a free consult to discuss further.
Why are you interested intaking medical cannabis?
Do you have any concerns withtaking medical cannabis?
Thank you for taking the time to complete this form!
DISCLAIMER: I am not making any attempt to prescribe medical treatment. It is not intended to replace a one-on-one relationship with a doctor or qualified health practitioner nor their medical advice.

By submitting this form, you are agreeing htat you are of appropriate age to use this form and to receive further communication from Bryony Mccord

For further information you can visit my website at

bryonymccord.com
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