Questionnaire C

Riverton Medical Healthcare

Medical Marijuana Questionnaire

List Any Symptoms

Weakness

Weight Loss

Blurry Vision

Dizziness

Hearing impairment

Ringing in ears

Tonsil Enlargement

Cough

Wheezing

Chest pain

Palpitations

Heart murmur

Abdominal pain

Vomiting

Arthritis

Joint pain

Back problems

Depression

Hallucinations

Memory loss

Mood changes

Anxiety

Psychiatric disorders

Headaches

Loss of conciousness

Fainting

Head injury

Peripheral neuropathy

Numbness

Tingling

Tremors

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Date (YYYY-MM-DD)(required)

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