Patient Self-Questionnaire YN I would like to pursue an individualized approach to optimize my CBD results. YN I’m seeking medical CBD for an ill child or adolescent. YN I have been diagnosed with cancer. YN I have a cardiac or respiratory condition (arrhythmia, hypertension, asthma etc). YN I have been diagnosed with diabetes. YN I have a mental health disorder (schizophrenia, bipolar, etc). YN I’m seeking CBD to manage/improve a chronic or complex medical condition. If you answered “Yes” to any of the above questions, seeking medical review of your situation is important to ensure safe and optimal medical CBD use. Please fill out the rest of this form. Your Name (required) Your Email (required) Phone Number Your Message