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1. What is your age?

2. What health conditions or symptoms do you have and wish to treat with Medicinal Cannabis?

3. Have you ever used medicinal Cannabis products?

4. Have you ever used cannabis for recreational purposes?

5. Are you currently treated by a physician or health care provider for conditions or symptoms you laid out above?

6. Is your physician or health care provider aware that you wish to use medicinal cannabis to treat your health condition?

7. If yes to above question, does your Physician or Health Care Provider support your use of medicinal Cannabis?

8. Please give details of any medicines, either prescription or bought over the counter, used to treat your medical conditions or symptoms?

9. Are you experiencing any effects (or side effects) of the medication you take. Please describe.

10. What results are you expecting from using Medicinal Cannabis products to treat your medical condition or symptom?

11. How did you hear about The Natural Remedy? Who referred you to us?

12. Is there any other information you would like to share with your consultant?

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