COPING WITH CANCER CANNABIS INTAKE FORM

COPING WITH CANCER CANNABIS INTAKE FORM

Patient Name
Patient Address:

MEDICAL HISTORY
Symptoms & Treatment Side Effects (Check all that apply)
What types of examinations have you had (Check all that apply)
What treatments have you had (Check all that apply)
Max. file size: 16 MB.

FAMILY MEDICAL HISTORY

Please check any of the following family members that have had cancer

LIFESTYLE AND SOCIAL LIFE

CANNABIS HISTORY

How are you using Cannabis (Check all that apply)