HCO Quality of life Questionnaire
Please fill out and submit the following form
Age
Your answer
Gender
Do you currently have a valid California Medical Marijuana License.
What Medical Conditions do you have.
Your answer
My condition limits the places where I can go
I sometimes feel like crying
My condition makes me feel embarrassed or depressed
I have difficulty dressing myself
I Struggle to do work around the house
I am unable to join in activities with my Friends/Family
I have unbearable Pain
I am tired all the time
I have to keep stopping what I am doing to rest
I have great difficulty getting meaningful sleep
My Condition creates problems with partner/close friends/family
Causes Sexual Difficulties
My condition is affecting my appetite
What drugs are you currently taking
Your answer
Are you having to take any drugs that are specifically for side effects of something else, if so what are they.
Your answer
How long have you had this condition and when were you diagnosed.
Your answer
Rate your pain level from 1(low) to 10 (intense) and if possible its localization
Your answer
Has anything given you really good relief from your condition, even if only temporarily and if yes, what was it.
Your answer
Are you interested in trying HCO
If you want someone to contact you please leave your contact information *Must be in California
Your answer
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