Contact Details

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Shipping Address

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History of heart problems, chest pain, shortness of breath, arrhythmias, pacemaker, or heart medications? Yes No

Currently treated for cancer or undergoing treatments? Yes No

Currently taking immunosuppressants or immunotherapy? Yes No

History of liver disease (e.g., hepatitis, elevated enzymes, fatty liver, cirrhosis)? Yes No

Psychiatric history (referred to psychiatrist/health service)? Yes No

Diagnosed with any of the following (select all that apply):

“None” cannot be selected with other options.

Currently or previously suicidal? Yes No

Family history of the following (select all that apply):

History of alcohol abuse or dependency? Yes No

Ever been under care of drug & alcohol services? Yes No

How many units of alcohol per week?

Do you use cannabis to reduce or eliminate prescribed medications? Yes No

If you currently use cannabis, how often?

How have you used cannabis? (select all that apply)

“Never” can’t be combined with other options.

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