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CannaCauses Foundation

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Cannabis Therapy™ Consultation Request

“Everyone deserves the medicine they need”

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Consultation Form New - Full Details

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Step 1 of 5

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Full Name*

First Last

Phone*

Email*

Diagnosis*

Multiple Sclerosis

Parkinsons

Cancer

Chronic Pain

PTSD

Depression

Anxiety

Arthritis

Other

Date of Diagnosis*

Month

Day

Year

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male

Female

Prefer Not To Answer

Age*

Date of Birth*

Month

Day

Year

Do you have a caregiver or support person?*

Yes

None

Caregiver Name*

Caregiver Email*

Caregiver Phone Number*

Relationship*

Are you employed?

Yes

No

I am employed as the following:*

If no, select one:*

No, I am retired

No, I am on work disability

No, I am unemployed

If on work disability, check one:*

I am permanently disabled

I am temporarily disabled

As of what date?*

Month

Day

Year

Disability: Can you walk or are you wheelchair bound?*

Are you an active military a Veteran or a First Responder?*

Yes

No

If yes, check one:*

Active Military

Veteran

First Responder

For “Service” related discounts upload applicable photo ID*

Max. file size: 50 MB.

Do you have or have you applied for a (MMJ) Medical Marijuana Card?*

Yes

No

Note: Having a card or having applied for one has its benefits however, NOT having one does NOT preclude you from starting the consultation process.

If yes, upload copy of (MMJ) Medical Marijuana Card or copy of application*

Max. file size: 50 MB.

Please thank who referred you to us.*

Physician

Friend

Dispensary

Other

Referral Contact/Name

Referral Phone

Primary Diagnosis*

Alzheimers

Arthritis

Asthma

Autism

Autoimmune Disease

Cancer

Crones

Dementia

Depression

MS

Paralysis

Physical Injury

Dry Skin Condition

PTSD

Other

Check all that apply

Alzheimers*

Stage/Type

Date Diagnosed

Arthritis*

Stage/Type

Date Diagnosed

Asthma*

Stage/Type

Date Diagnosed

Autism*

Stage/Type

Date Diagnosed

Autoimmune Disease*

Type

Date Diagnosed

Cancer*

Stage/Type

Date Diagnosed

Crones*

Stage/Type

Date Diagnosed

Dementia*

Stage/Type

Date Diagnosed

Depression*

Stage/Type

Date Diagnosed

MS*

Stage/Type

Date Diagnosed

Paralysis*

Stage/Type

Date Diagnosed

Physical Injury*

Type

Date Diagnosed

Dry Skin Condition*

Type

Date Diagnosed

PTSD*

Stage/Type

Date Diagnosed

Other Condition*

Stage/Type

Date Diagnosed

Please Rate Your Symptoms

On a scale of 1 to 10, 10 being the worst, rate on AVERAGE the following. Ratings based on how you feel before taking the medication and after taking the medication. Use Add symbol if taking more than 1 medication for symptom

I experience the following:*

Anxiety

Depression

Falling or Staying Asleep

Spasticity

Neuropathy

Nerve Pain

Muscle Pain

Fibromyalgia

Seizures

Tremors

Migraines

Inflammation

Joint Pain

Cancer

Other

Anxiety*

Please Indicate your level of anxiety (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Side Effects

Depression*

Please Indicate your level of Depression (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Sleep*

Please Indicate your level of Sleep issues (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Spasticity*

Please Indicate your level of Spasticity (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Neuropathy*

Please Indicate your level of Neuropathy (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Nerve Pain*

Please Indicate your level of Nerve Pain (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Muscle Pain*

Please Indicate your level of Muscle Pain (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Fibromyalgia*

Please Indicate your level of Fibromyalgia (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Seizures*

Please Indicate your level of Seizures (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Tremors*

Please Indicate your level of Tremors (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Migraines*

Please Indicate your level of Migraines (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Inflammation*

Please Indicate your level of Inflammation (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Joint Pain*

Please Indicate your level of Joint Pain (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Cancer*

Please Indicate your level of Cancer (1-10), 10 being the worst, before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Other*

Please Indicate your level of symptoms (1-10), 10 being the worst, before medicating and after medicating

Ailment

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Example: Medication: Aspirin | Before: 10 | After: 5 | How long have you been on this medication: 1 year | Milligrams taken daily: 50mg | Side effects: drowsiness

Do you take medications for other reasons?*

Yes

No

If yes, please explain

Which symptom(s) is most problematic?*

Anxiety

Depression

Falling or Staying Asleep

Spasticity

Neuropathy

Nerve Pain

Muscle Pain

Fibromyalgia

Seizures

Tremors

Migraines

Inflammation

Joint Pain

Cancer

Other

If you could reduce any medication(s) what would it be?*

Have you ever or do you currently use cannabis to manage any of your symptoms?*

Yes

No

Previously or Currently?*

Previously

Currently

Cannabis Usage*

Symptom

Type of Cannabis

Effective? Yes or No

Cannabis Type Examples: Smoke, Vape, Tincture, Edible, Topical

Are you open to paying it forward?*

Yes

No

If yes: I would be willing to participate in the following;*

Study

Survey

Testimonial

Workshop

(Check all that apply)

Disclaimer & Consent*

I agree to the privacy policy.

Please read and agree to the website terms of use.

Schedule Preferences

Conference Type*

Phone

Video

Time*

Mornings

Afternoons

Evenings

Days*

Weekdays

Weekends

Any Day

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Our Mission

To emphasize relations that result in the effective growth and responsible use of cannabis and its therapeutic benefits. To serve as a credible source for research, education, and information for anyone seeking trust, credibility, and integrity above all. To pay it forward by supporting generally charitable activities that benefit the most vulnerable and heroic among us.

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Blog
Resources
- Cannabis in the Media
- Peer Reviewed Articles
Your Cart

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Consultation
Blog
Resources
- Cannabis in the Media
- Peer Reviewed Articles
Your Cart

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info@cannacauses.org

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