Cannabinoid Hyperemesis Syndrome Survey
The purpose of this form is to collect data about those who have experienced Cannabinoid Hyperemesis Syndrome. You may remain anonymous. If you have any questions about this survey, please email Alice Moon at alicemoon@alicemoon.la
Email address *
What is your name? (Not Required)
May I contact you regarding your CHS experience? *
Where are you located? *
How old are you? *
Do you have CHS? *
How long were you consuming cannabis before you experienced symptoms of CHS? *
How often were you using cannabis? *
What was your preferred way to use cannabis? *
Required
Did you smoke pesticide free cannabis? *
Did you grow/smoke your own cannabis without pesticides? *
What symptoms did you experience? *
Required
How long did you have CHS before doctors discovered the problem? *
Required
How long did your first "episode" with CHS last? *
An episode refers to when you were experiencing the symptoms. Example: Alice Moon threw up for 14 days - this was her first episode.
Have you quit cannabis completely? *
If you quit consuming, how long did your symptoms continue after you stopped using cannabis?
Example: Alice quit consuming and her symptoms continued for 14 days.
Clear selection
If you went back to consuming cannabis after taking a break, did your symptoms come back? *
Were you hospitalized because of your symptoms? *
How many "episodes" of CHS have you experienced? *
An episode refers to when you were experiencing the symptoms. Example: Alice Moon threw up for 14 days - this was her first of three episodes.
What provided you with some relief when going through an episode? *
Required
Did you try any of the following medications? *
Required
If you answered yes to the previous question, did the medication provide relief? *
Required
Did you have any adverse/negative side effects from the medicine(s) you took? If so, please describe:
Did you experience any of the following withdrawals when you quit cannabis: *
Required
Do you currently use CBD? *
Did you ever use CBD? *
Has CBD triggered CHS for you? *
Did you feel the urge to run when going through an episode?
Clear selection
Do you have mental or physical health conditions that existed before you experienced CHS? *
If yes, what conditions? *
Required
Are you on medication? If yes, please list what medications and why. (Not required)
Were you using cannabis for medicinal purposes? If yes, please share why. (Not Required)
Have you had your gallbladder unnecessarily removed? *
What do you believe is the cause of CHS? *
Required
Have you told anyone that you have CHS? *
If you have told people about CHS, what were their reactions?
How much money have you spent out of pocket on medical bills related to CHS? *
Do you have health insurance? *
How has your life changed since being diagnosed with CHS?
Share more about your experience with CHS
How did you find this form? *
Required
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