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Presenting Diagnosis
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If Other, please specify:
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Is this an official or a suspected diagnosis?
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Approximate Date of Diagnosis:
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Previous Treatments That Failed:
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Previous Treatments That Helped:
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For PTSD: which of the following symptoms are most concerning to you?
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If other, please specify:
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Which symptoms are you specifically looking for help with?
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Have you tried marijuana in the past?
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Which form(s) of marijuana have you tried?
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Which form(s) of marijuana have helped?
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Do you require assistance from a caregiver?
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If yes, please specify:
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Please provide contact information for caregiver:
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Females Only
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Are you pregnant?
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Do you plan on becoming pregnant in the next year?
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Are you currently using prescription birth control?
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Besides prescription birth control, do you use other forms of contraceptives?
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If yes, what?
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