Healing & Hemp for Heroes - APPLICATION
Email *
First & Last Name *
Address, City, State, Zip *
Birth Date *
MM
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DD
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Branch of Service *
Diagnosis from a provider? *
Number of concussions? *
Do you have a TBI? (Traumatic Brain Injury) *
Average Daily Pain Level? (10 being severe) *
Location of pain? *
What surgeries have you had? *
What has helped your pain? *
What medications do you currently use?(If none, write NA) *
What supplements do you currently use? (If none, write NA) *
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