Curious if you Qualify for Medical Cannabis?
Take this short survey to find out. Estimated time 6-10 minutes.
Complete this form
Are you a Missouri Resident?
What is your sex?
Are you currently taking any medications?
Do you have any allergies?
Are you disabled?
Are you a veteran?
Please Read and Acknowledge:
I am being evaluated for a physician's recommendation for the medicinal use of cannabis. The physician will make this recommendation based, in part, on the medical information I have provided. I have and will not misrepresent my medical condition, not for recreational or non-medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws in the possession, use, sale/purchase and/or distribution of cannabis. I have been informed of and understand the following:
The federal government has classified marijuana as a Schedule 1 controlled substance. Schedule 1 substances are defined, in part, as having (1) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana, even in states that have modified their laws to treat marijuana as medicine.
By clicking YES, I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for benefits.
Which Pre-Qualifying Medical Condition applies to you? If you aren't sure which pre-qualifying condition applies to you, select "any other medical condition...".
Do you have your Medical Records or Medical History from your Primary Care Provider that shows the above selected Qualifying Condition available or easily accessible?
Has a doctor ever denied or restricted your activity for any reason? *Has a doctor ever denied or restricted your activity for any reason?
Have you ever been hospitalized?
Have you ever been treated for an emotional condition?
Have you ever had a seizure?
Do you have any rashes, sores, or
other skin problems?
Have you been diagnosed with
Adult Onset Diabetes?
Are you trying to lose or gain weight?
Have you had any problems with your eyes or vision?
Have you ever had numbness, tingling, or weakness in your arms or legs?
Do you currently consume cannabis?
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