Personalized Cannabis Recommendation Coaching Session Questionnaire

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Please fill out this form and submit below.

Email *

What's your first name? *

How old are you?

*If you are under the age of 21, we cannot help you. (Please exit this questionnaire)

21-24

25-40

41-56

57-75

76-95

Where do you currently live? (City, State & Country) *

Do you have any of the following current medical problems/conditions? *

Acid Reflux

Alzheimer's Disease

Aniexty

Asthma

Atrial Fibrillation

Bradycardia (slow heart rate)

Bronchitis

Cirrhosis

Congestive Heart Failure

Constipation/Diarrhea

COPD

Dementia

Depression

Diabetes

Dialysis

Dyspepsia

Emphysema

Epilepsy

Fatty Liver

Female Reproductive Issues

Food Allergies

Gallstones

Headaches

Heart Attack

Hepatitis

High Blood Pressure

High Cholesterol

IBS

Kidney Failure

Kidney Stones

Multiple Sclerosis

Nausea/Vomiting

Parkinson's Disease

Pneumonia

Stroke

Supra Ventricular Tachycardia (SVT)

Tachycardia (too fast heart rate)

Thyroid Problems

Ventricular Fibrillation (implanted defibrillator)

Other:

Required

Please list ALL medications you are currently taking... *

What is your number one health and wellness complaint that we can help you with? *

What is your second health and wellness complaint that we can help you with? *

What is your experience with cannabis and cannabis-related products? *

Brand New - I've never used anything before

Newbie/Novice - I've tried one or two products, but I'm still learning

Intermediate - I use products as needed

Experienced - I use products all the time

Have you ever visited a legal medical/recreational cannabis dispensary? *

Yes

Do you currently consume any cannabis or cannabis-related products? If so, what kind? (Tincture, gummy, smoke, topical, etc.) *

What are you interested or willing to try? *

Cannabis Flower (smoke or vape)

CBD Flower (smoke or vape)

Topicals (creams, lotions, patches)

Tinctures

Edibles (gummies, capsules, tablets)

Concentrates (dabs, vape pens)

Other:

Required

Is there anything keeping you from consuming cannabis or cannabis-related products? *

Job

Housing

City/Local Government

Family/Friends

Other:

Required

Is there anything else we need to know?

By participating in this coaching session, you agree to the following terms:

*I am 21 years of age or older.

*This information provided by me is true to the best of my knowledge.

*I am aware that Millennial420 is only providing their opinion; this is not medical information and has not been evaluated by the FDA.

*These product recommendations are not intended to diagnose, treat, cure or prevent any disease.

*I agree to consult a physician before using any cannabis or cannabis-related products if I am pregnant, nursing, have a serious health condition or am using prescription medications.

*I hereby certify that I understand the risks associated with this coaching session, if any, and agree that Millennial420 shall not be responsible for any injuries or losses sustained by me during or after this coaching session.

Yes, I agree

Thank you so much for filling out this questionnaire! Please give us 72 hours to review and write up your personalized recommendation plan. We will send it to the email on file. In the meantime, feel free to browse our website and shop our merchandise. If you have any additional questions or concerns, please email us at millennial420team@gmail.com.

All this information is confidential. We will not sell your information.

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