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Giving Hemp Patient Registry
Safe access for patients by patients.
These questions are necessary to create a baseline and keep track of specific metrics through your journey.
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* Indicates required question
Email
*
Your email
Phone Number
*
Your answer
Name (last, first, middle)
Your answer
Date of Birth
MM
/
DD
/
YYYY
Height and Weight
Your answer
Address
Your answer
Sex
Male
Female
Clear selection
Race
Your answer
Have you been diagnosed with cancer in the past?
Yes
No
Clear selection
What is your exact cancer diagnosis? (include types and dates)
Your answer
Is there a family history of cancer, if so, which kind?
*
Your answer
What treatments are you currently on?
Your answer
Current medications (relating to this diagnosis)
Your answer
Have you used hemp (cannabis) products before? When? How?
Your answer
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