Healing & Hemp for Heroes - APPLICATION
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Email address
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Your email
First & Last Name
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Your answer
Address, City, State, Zip
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Your answer
Birth Date
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MM
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DD
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YYYY
Branch of Service
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Your answer
Diagnosis from a provider?
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Your answer
Number of concussions?
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Zero
1-2
3-4
More than 5
Do you have a TBI? (Traumatic Brain Injury)
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Yes
No
I don't know
Average Daily Pain Level? (10 being severe)
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1
2
3
4
5
6
7
8
9
10
Location of pain?
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Your answer
What surgeries have you had?
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Your answer
What has helped your pain?
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Your answer
What medications do you currently use?(If none, write NA)
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Your answer
What supplements do you currently use? (If none, write NA)
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Your answer
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