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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gender* Male Female Prefer Not To Answer Preferred Contact Method (Check All That Apply)* Phone Text Email Disability: Can you walk or are you wheelchair bound?*Walking is no problemI use a walker part-timeI use a walker full-timeI use a wheelchair part-timeI use a wheelchair full-timePlease 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*CIS (Clinically Isolated Syndrome)RRMS (Relapsing-Remitting MS)SPMS (Secondary Progressive MS)PPMS (Primary Progressive MS)Unsure/OtherPlease Specify Stage Of Parkinson's* What Stage Of Cancer*Stage 1Stage 2Stage 3Stage 4What Type Of Cancer* What Stage Of Chronic PainStage 1Stage 2Stage 3Stage 4What Type Of Chronic Pain* What Stage Of PTSDStage 1Stage 2Stage 3Stage 4What Type Of PTSD* What Stage Of DepressionStage 1Stage 2Stage 3Stage 4What Type Of Depression* What Stage Of AnxietyStage 1Stage 2Stage 3Stage 4What Type Of Anxiety* What Stage Of ArthritisStage 1Stage 2Stage 3Stage 4What Type Of Arthritis* Please Specify Other Diagnoses* What StageStage 1Stage 2Stage 3Stage 4What 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?*YesNoOtherRelationship* Caregiver Email* Caregiver Phone Number*Is your caregiver your Point of Contact?*Yes, please call my caregiver/spouse/parent directlyNo, you may contact me directlyPrimary Language*EnglishSpanishBi-lingualOtherPlease 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?*Yes, this has happened beforeNo, this has never happenedWhich medication and for what reason?* Please Rate The FollowingOn 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 symptomDo you experience Anxiety? Yes No Anxiety*Please Indicate your level of anxiety before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailySide Effects Add RemoveComments / Notes*If none please put N/ADo you experience Depression? Yes No Depression*Please Indicate your level of Depression before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Seizures? Yes No Seizures*Please Indicate your level of Seizures before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Neuropathy? Yes No Neuropathy*Please Indicate your level of Neuropathy before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Spasticity? Yes No Spasticity*Please Indicate your level of Spasticity before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you have trouble with sleep Yes No Sleep*Please Indicate your level of Sleep before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Pain? Yes No Pain*Please Indicate your level of Pain before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you have Fibromyalgia? Yes No Fibromyalgia*Please Indicate your level of Fibromyalgia before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience migraines? Yes No Migraines*Please Indicate your level of Migraines before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Joint Pain or Arthritis? (Please specify in comments) Yes No Joint Pain or Arthritis*Please Indicate your level of Joint Pain or Arthritis before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Muscle Pain? Yes No Muscle Pain*Please Indicate your level of Muscle Pain before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Psoriasis or Dry Skin? (Please specify in comments below) Yes No Psoriasis or Dry Skin*Please Indicate your level of Psoriasis or Dry Skin before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/ADo you experience Tremors? Yes No Tremors*Please Indicate your level of Tremors before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/AAre you currently undergoing chemotherapy? Yes No Chemotherapy*Please Indicate your level of Chemotherapy before medicating and after medicating MedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / Notes*If none please put N/AAre you medicated for other purposes? Yes No Other*AilmentMedicationBeforeAfterHow long have you been on this medicationMilligrams Taken DailyEffects/Side Effects Add RemoveComments / 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 No 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 No Are You Still Using Topical Products?* Yes No Are You Still Using Edible Products?* Yes No Are You Still Using Smoking/Vaping Products?* Yes No 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 No 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 No Have You Recieved It?* Yes No If No, Why Not?*MMJ is not legal in my StateMy condition does not qualify for a MMJ Card in my StateMy Condition qualifies for for the MMJ Card but I have not applied for onePlease Provide A Photo Of Your Medicinal Card*Max. file size: 50 MB.Is It Pending?* Yes No Referred By*another patientphysicianfriendotherName 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 No 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 timeConsultation Preference* Video Phone Product NameTotal 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. CAPTCHACredit Card