TRILL ALTERNATIVES CLIENT INFORMATION FORM
Please fill out the following questions with the best-detailed answers that you feel comfortable with. We appreciate your time and want you to know that your responses will give us a better understanding on how we may assist your specific needs. This information is used for consultation purposes only. Thank you!
1. TODAYS DATE:
MM
/
DD
/
YYYY
2. ARE YOU AN MMJ CARDHOLDER?
*We can only make sales to Colorado MMJ cardholders
3. WHO REFERRED YOU TO US?
Your answer
4. CLIENT NAME:
(or alias if preferred)
Your answer
5. AGE TODAY:
Your answer
6. HEIGHT & WEIGHT:
Your answer
7. PHONE NUMBER:
Your answer
8. E-MAIL:
Your answer
9. PREFERRED METHOD OF CONTACT:
*By providing us with contact information you are giving us your permission to contact you at these numbers and addresses for consultation purposes
Required
10. BEST DAY TO CONTACT (PHONE):
Required
11. BEST TIME TO CONTACT (PHONE):
Required
12. CITY OF RESIDENCE:
Your answer
13. PLEASE DESCRIBE YOUR AILMENT(S)/DIAGNOSIS:
Your answer
14. LIST SURGERIES/HOSPITALIZATIONS/HISTORY:
Your answer
15. PLEASE LIST CURRENT AND PAST MEDICATIONS AND SUPPLEMENTS:
Include dates, medication name, dosing, frequency & details (use box #35 for additional space)
Your answer
16. PLEASE LIST ANY ALLERGIES:
Your answer
17. PLEASE MARK ALL THAT APPLY TO YOU:
Required
18. PLEASE LIST YOUR PRIMARY SYMPTOMS:
Your answer
19. WHAT MAKES YOUR SYMPTOMS BETTER?
Your answer
20. WHAT MAKES YOUR SYMPTOMS WORSE?
Your answer
21. HOW WOULD YOU RATE YOUR SYMPTOMS WITHOUT MEDICATION OR TREATMENT?
1 is low, 10 is high
22. HOW WOULD YOU RATE YOUR SYMPTOMS WITH MEDICATION OR TREATMENT?
1 is low, 10 is high
23. HOW FREQUENTLY DO YOU EXPERIENCE YOUR SYMPTOMS?
Required
24. PLEASE MARK ALL THAT APPLY REGARDING YOUR DIET AND EATING HABITS:
Required
25. HOW FREQUENTLY DO YOU PHYSICALLY EXERCISE?
Required
26. PLEASE DESCRIBE YOUR SLEEPING HABITS. HOW MANY HOURS DO YOU SLEEP EACH NIGHT?
Your answer
27. PLEASE MARK ALL THAT APPLY TO YOU:
28. HOW WOULD YOU RATE YOUR LEVEL OF EXPERIENCE WITH CANNABIS?
29. HOW LONG HAVE YOU BEEN USING CANNABIS MEDICINALLY? DESCRIBE YOUR MEDICINAL CANNABIS HISTORY:
Your answer
30. WHAT IS YOUR GOAL OR INTENTION WITH CANNABIS TREATMENT?
Your answer
31. WHAT CANNABIS DELIVERY METHODS HAVE YOU TRIED?
Required
32. PLEASE LIST ANY SPECIFIC PRODUCTS YOU HAVE TRIED THAT WORKED FOR YOU:
Include product/strain, dose tried & effects
Your answer
33. PLEASE MARK ALL THAT YOU ARE INTERESTED IN LEARNING MORE ABOUT:
34. ARE YOU WILLING TO FILL OUT PATIENT TESTIMONIAL SHEETS ABOUT YOUR EXPERIENCE(S) WITH CANNABIS MEDICATIONS?
35. PLEASE USE THIS SPACE FOR ANY ADDITIONAL NOTES:
(OTHERWISE LEAVE BLANK)
Your answer
PLEASE READ CAREFULLY AND INITIAL BELOW
All responses have been filled out accurately to the best of my knowledge and understanding.

Please be advised that the content of this document is provided for general informational purposes only. Any content herein is not intended to be, nor constitutes professional medical advice or a formal treatment recommendation. Use of this information or Trill Alternatives products is not intended to, nor does it, create a physician-patient or health care provider-patient relationship between Trill Alternatives and the user. We recommend that you consult a physician or other qualified health care provider prior to starting any new treatment or with any questions you may have about your health. These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

While we hope you find these resources and our products and services helpful, reliance on any of the information, products or services provided by Trill Alternatives is solely at your own risk. In no event will Trill Alternatives be liable for any medical or non-medical losses, damages, or injuries arising out of or in connection with the use of our products, services, or the information provided on this document, regardless of cause. Trill Alternatives further disclaims all representations and warranties related to the content of this document and use of its products and services. Trill Alternatives products contain medical marijuana and are produced without regulatory oversight for health, safety or efficacy and there may be health risks associated with consumption of such products

By acting on this information and/or patronizing our business, you are accepting all the terms of this disclaimer notice. Nothing in this disclaimer notice excludes or limits any warranty implied by law, which it would be unlawful for Trill Alternatives to exclude.

For registered Colorado medical marijuana patients only.

CLIENT NAME:
Your answer
CLIENT E-SIGNATURE INITALS:
*Signing your initials to this box represents your signature
Your answer
TODAY'S DATE:
MM
/
DD
/
YYYY
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