Intake Form - Canna Causes Foundation

CannaCauses Foundation

Cannabis Therapy™ Consultation Request

“Everyone deserves the medicine they need”

"*" indicates required fields

Step 1 of 5

20%

Full Name*

First Last

Phone*

Email*

Address*

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

Gender*

Male

Female

Prefer Not To Answer

Preferred Contact Method (Check All That Apply)*

Phone

Text

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

Please Upload A Photo of A Valid ID/Driver License*

Max. file size: 50 MB.

Physicians Name*

Physicians Phone Number*

Primary Diagnosis*

Multiple Sclerosis

Parkinsons

Cancer

Chronic Pain

PTSD

Depression

Anxiety

Arthritis

Other

What Type Of Multiple Sclerosis*

Please Specify Stage Of Parkinson's*

What Stage Of Cancer*

What Type Of Cancer*

What Stage Of Chronic Pain

What Type Of Chronic Pain*

What Stage Of PTSD

What Type Of PTSD*

What Stage Of Depression

What Type Of Depression*

What Stage Of Anxiety

What Type Of Anxiety*

What Stage Of Arthritis

What Type Of Arthritis*

Please Specify Other Diagnoses*

What Stage

What Type

Date of Diagnosis*

Month

Day

Year

Age*

Height*

Weight*

Please enter a number from 1 to 1000.

Are You The Caregiver, Spouse, or Parent?*

Relationship*

Caregiver Email*

Caregiver Phone Number*

Is your caregiver your Point of Contact?*

Primary Language*

Please Type In Your Language*

Has your doctor ever taken you off of any of your meds for any period of time? Or have you been on them consistently?*

Which medication and for what reason?*

Please Rate The Following

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

Do you experience Anxiety?

Yes

Anxiety*

Please Indicate your level of anxiety before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Side Effects

Comments / Notes*

If none please put N/A

Do you experience Depression?

Yes

Depression*

Please Indicate your level of Depression before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Seizures?

Yes

Seizures*

Please Indicate your level of Seizures before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Neuropathy?

Yes

Neuropathy*

Please Indicate your level of Neuropathy before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Spasticity?

Yes

Spasticity*

Please Indicate your level of Spasticity before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you have trouble with sleep

Yes

Sleep*

Please Indicate your level of Sleep before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Pain?

Yes

Pain*

Please Indicate your level of Pain before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you have Fibromyalgia?

Yes

Fibromyalgia*

Please Indicate your level of Fibromyalgia before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience migraines?

Yes

Migraines*

Please Indicate your level of Migraines before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Joint Pain or Arthritis? (Please specify in comments)

Yes

Joint Pain or Arthritis*

Please Indicate your level of Joint Pain or Arthritis before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Muscle Pain?

Yes

Muscle Pain*

Please Indicate your level of Muscle Pain before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Psoriasis or Dry Skin? (Please specify in comments below)

Yes

Psoriasis or Dry Skin*

Please Indicate your level of Psoriasis or Dry Skin before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Do you experience Tremors?

Yes

Tremors*

Please Indicate your level of Tremors before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Are you currently undergoing chemotherapy?

Yes

Chemotherapy*

Please Indicate your level of Chemotherapy before medicating and after medicating

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

Are you medicated for other purposes?

Yes

Other*

Ailment

Medication

Before

After

How long have you been on this medication

Milligrams Taken Daily

Effects/Side Effects

Comments / Notes*

If none please put N/A

What is your biggest concern? (i.e. symptoms spreading/progressing, focused pain area)*

Previous Cannabis Usage*

Never Used Before

Used Moderately

Used Heavily

Was it used for Medicinal Purposes?*

Yes

Did It Work?*

Yes, but no longer working

Yes, but no longer available to me for purchase

Not really/I couldn't see much of a difference

Not at all

What Forms of Cannabis? (Check All That Apply)*

Tincture

Topical

Edible

Smoke/Vape

Are You Still Using Tincture Products?*

Yes

Are You Still Using Topical Products?*

Yes

Are You Still Using Edible Products?*

Yes

Are You Still Using Smoking/Vaping Products?*

Yes

Do you Have A Working Disability?*

Yes (Permanent)

Yes (Temporary)

No, I do not

Tolerance Level*

(Ex: If you took aspirin for an average headache would you need a small dose, regular dose, high dose or I don't know)

Smaller Dose

Regular Dose

Higher Dose

I Dont Know

Time of Day symptoms are most often experienced?*

Morning

Mid Day

Night

All The Time

Unsure

Are you a veteran or military?*

Yes

Please Upload Valid Photo of ID*

Max. file size: 50 MB.

Have you applied for a Medicinal Marijuana Card? (Note: Card not required for consultation.)*

Yes

Have You Recieved It?*

Yes

If No, Why Not?*

Please Provide A Photo Of Your Medicinal Card*

Max. file size: 50 MB.

Is It Pending?*

Yes

Referred By*

Name Of Who Referred You*

If Other, Please type in valid entry*

Are you open to paying it forward by participating in a confidential case study?*

Yes

Time Preference*

Mornings (between 8:00am - 10:00am)

Noon (between 11:00am - 1:00pm)

Evenings (between 3:00pm - 5:00pm)

please keep in mind to choose a time slot that would work for your caretaker/spouse/parent to be in on the call. Please reserve 60-90 minutes of uninterrupted time

Consultation Preference*

Video

Phone

Product Name

Total

Consent*

I agree to the privacy policy.

Once your intake form is complete, click the blue "Add to Cart" button
Proceed to your cart to submit your form and payment. (Note: Click the cart icon at the top right corner of webpage)
Once your payment is submitted you will receive a confirmation email to set you up for a Consultation with Aryn Sieber.

CAPTCHA

Credit Card

CannaCauses Foundation

Please Rate The Following

Stay in Touch

Our Mission

Links

Keep in Touch

Copyright 2023 © All rights Reserved. CANNA Causes