Instructions

Answer the questions as the relate to you. For most answers, check the box(es) most applicable to you and/or fill in the blanks.

About You

1. Contact Information

(Select only one.)

First Name

Last Name

Phone Number

E-mail Address

- -

2. Your Age

17 or Younger

18-25

23-35

36-45

46-55

56-65

66-75

76 or Older

3. Your Gender

Female

Male

Other:

4a. Diagnosis (Official)

(Select all that apply.)

Cancer

Type: Stage: Treatments: Radiation Chemo Surgery

HIV/AIDS

Epilepsy

Multiple Sclerosis

Heart Disease

PTSD

Psychological Imbalance

Other:

4b. Diagnosis (self-deteremined)

5. Symptoms you are expriencing/addressing

(Select all that apply.)

Neuropathy

Sleep

Side-Effects from Meds

Nausea

Trouble Eating / Digesting

Cognitive Impairment

Skin Issues

Pain

Anxiety

Inflammation

Respiratory Difficulty

Depression

Other:

Current Income Status

6. Current Employment Status:

(Select only one.)

Employed [full-time]

Employed [part-time]

Student

Unemployed

Homemaker

Retired

SSI

SSDI

7. Yearly Income

(Select only one.)

Under $25,000

$25,000 - $39,999

$40,000 - $49,999

Over $50,000

Fixed Income

8. Insurance Coverage

(Select only one.)

MediCal

MediCare

Healthy S.F.

Uninsured

Private Insurance

About Your Cannabis Usage

9. With which type of Cannabis do you most frequently medicate?

(Select all that apply.)

Indica

Indica Dominant Hybrid

Sativa

Sativa Dominant Hybrid

Hybrid (50/50)

High-CBD strains

I don't know

9. How do you medicate?

(Select all that apply.)

Smoke Vaporize

Flowers (bud)

Flowers (bud)

Hash

Wax / Budder / Shatter / Glass

Oil

Edibles

Tinctures / Sublinguals

Capsules

Topicals

11. Are there any items to which you have a sensitivity?

(Describe below. For example: "sativas make me anxious" or "I'm allergic to dairy".)

12. Do you have a caregiver who picks up meds on your behalf?

(Select only one.)

Yes No