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      Medical Marijuana Cannabis Patient Survey

            If you have any problems using this form?
                     Please just email us & let us know!




             If you are a Medical Marijuana Patient?

               Please take 5 minutes & Fill out this Online Survey!

It will never be released to any Law Enforcement Group or Government Agency. It will Just help us to Learn how we can help
 you better. & To show us any area’s that we can use for Research. & To Help Make a Better Profile of the Average Medical
 Marijuana Patient Statistic’s & Their Personal Needs.

Just try to answer all the questions as best you can.

It does NOT have to have your full real name on it!

Just be as truthful & thorough as you can please!

Name: (or Alias)
Email Address:
Town & State:
Medical Condition:
(if applicable)

Ctrl-Click to select multiple options

Please give a brief explanation in your own words:
What symptoms are you seeking to alleviate:

Ctrl-Click to select multiple options

Please give a brief explanation in your own words:

Have you previously used Cannabis to treat your condition?
Yes No 

In your assessment, is Cannabis effective in treating your condition?
Yes No 

How do you compare Cannabis to other medications in alleviating your symptoms?
Same More Effective Less effective 

Considering the side effects of other medications and of Cannabis, what is your personal assessment of the risk of Cannabis use compared to that of your other medications?

What other medications are you currently taking? 

List Names, Dosage, & For what Medical Condition.

Do you pay for the Medical Cannabis/Marijuana you use?
Yes No 

If yes how much do you pay? & for what type of strain.

How much medicine do you need to take to ease your medical symptoms?
Please list in Grams per day, & Strain if known

What method do you use to take your medical marijuana?

Bowl Joint Water Bong Vaporizer

Suppository Tea/Tincture  Compress

What type of Cannabis have you found to be most effective in alleviating your symptoms?
Indica Sativa Combination of both Unknown

Can you name and comment on the Cannabis Strain’s you have used before: (If Known)

Do you have your Doctors Recommendation for Medical use?
Yes No Need to get one.

Have you talked openly with your Doctor on your Medical Cannabis use? 
If not we strongly recommend that you openly talk to your Doctor.  

Please Feel Free To Refer Your Doctor To This Site

Yes No Will Talk With My Doctor My Next Visit

If you live in a State that does not have a Medical Marijuana Law. Then I would not waste your time the first time you meet your New Doctor asking for a written recommendation! You need to take your time, Build up good Communication with your Doctor, & Let him know how you feel it helps you! Then 6 to 9 months on down the road, See if he will write a recommendation for Medical Cannabis. But If he will not write a recommendation, Then each time you meet make sure you bring up your medical usage & have him/her write it into you medical records, Because then they are monitoring your medical marijuana usage, & it will help to enable you to use a "Medical Necessity Defense" in a court of law.

Its the next best thing to a written recommendation. & If you are a DR Please do this for you medical patients! Yes we wish that you would write a written recommendation, The Federal Appeals Court has all ready Ruled & Protected your medical rights as a DR to write a recommendation for medical cannabis, But if you are still concerned about writing a recommendation, Then please at lest write into the patients records each visit their medical marijuana usage & help protect your patients!

Do you favor the legalization of marijuana cannabis for medical purposes?
Yes No 

Is there anything else you would like to say about Medical Marijuana?

Disclaimer: I understand and accept that this information will be used to help learn how we can help the Medical
 Marijuana Patients better. It will never be released to any Law Enforcement Group or Government Agency!

Stay Well Everybody!