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Patient Self-Questionnaire

I would like to pursue an individualized approach to optimize my CBD results.

I’m seeking medical CBD for an ill child or adolescent.

I have been diagnosed with cancer.

I have a cardiac or respiratory condition (arrhythmia, hypertension, asthma etc).

I have been diagnosed with diabetes.

I have a mental health disorder (schizophrenia, bipolar, etc).

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)

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The statements made regarding these products have not been evaluated by the Food and Drug Administration. The efficacy of these products has not been confirmed by FDA-approved research. These products are not intended to diagnose, treat, cure or prevent any disease. All information presented here is not meant as a substitute for or alternative to information from healthcare practitioners. Please consult your healthcare professional about potential interactions or other possible complications before using any product. The Federal Food, Drug and Cosmetic Act requires this notice.

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