Pre-Qualification Questionnaire

 

Do you suffer from:

q                 AIDS
q                 Anorexia
q                 Arthritis
q                 Cachexia/Wasting Syndrome
q                 Cancer
q                 Chronic Pain
q                 Glaucoma
q                 Migraine Headaches
q                 Persistent Muscle Spasms
q                 Seizures
q                 Chronic Nausea

Do you suffer from: 

q                 Asthma      
q                 Parkinson Syndrome     
q                 Epilepsy   
q                 Multiple Sclerosis       
q                 Depression

 

Do you suffer from: 

q       Chronic pelvic pain
q       Severe menstrual cramps
q       Severe premenstrual syndrome
q       Painful intercourse
q       Chronic abdominal pain
q       Irritable bowel syndrome (IBS)
q       Colitis
q       Inflammatory bowel disease
q       Interstitial cystitis
q       Urinary incontinence

  

Do you suffer from: 

q       Anxiety
q       Depression
q       Bipolar disorder
q       Attention deficit disorder
q       Manic-depressive disorder
q       Obsessive-compulsive disorder
q       Impulse control disorder
q       Severe grief reaction
q       Phobias
q       Situational stress reaction disorder
q               Insomnia
q             Posttraumatic Stress Disorder

 

Do you suffer from: 

q       Chronic sciatica
q       Chronic back pain
q       Chronic neck pain

 

Do you suffer from:  

q       Radiculopathy
q       Neuralgia
q       Neuritis
q       Radiculitis
q       Reflex sympathetic dystrophy syndrome
q       Degenerative disc disease

 

 

Do you suffer from: 

q       Cerebral palsy
q       Quadriplegia
q       Parkinson's syndrome
q       Tourette's syndrome
q       Spinal cord injury
q       Tremors

 

Do you suffer from any chronic disorder either medical or psychiatric that substantially limits your ability to conduct daily living activities?

Yes           □ No

   

Would your chronic disorder if not alleviated cause a serious harm to your safety or physical or mental health?

Yes           □ No

   

Have you had a non-satisfactory or poor response to your medical treatments to date regarding your medical condition?

Yes           □ No

   

Have you had a non-satisfactory or poor response to any prescription or over-the-counter medications to treat your medical disorder?

Yes           □ No

  

Do you have a primary care provider?

Yes           □ No

 

Have you discussed the option of medical marijuana with your primary care provider?

Yes         □ No  

 

Do you have a copy of your medical records that are pertinent to your serious illness, or chronic medical symptoms?

Yes         □ No

   

Are you familiar with the possible side effects associated with medicinal marijuana?

Yes         □ No

   

Are you familiar with the legalities associated with the use of medicinal marijuana?

Yes         □ No

   

Has marijuana provided relief of your condition till now?

Yes        □ No

 

Do you have a valid California Identification Card?

Yes           □ No