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Question 1
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Yes
No
Do you have a chronic condition lasting more than 3 months that has been diagnosed by a doctor? (e.g. chronic pain, anxiety, depression, insomnia, etc.)
Question 2
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Yes
No
Have you tried conventional prescription medication for your condition?
Question 3
*
Yes
No
Has the medication been unsuccessful in fully treating your symptoms, or does it cause adverse side effects?
Question 4
*
Active psychosis
Drug dependence or substance abuse
Cardio pulmonary disease
Pregnant or breastfeeding
None of the above
Do you have any of the following conditions?
Question 5
*
Yes
No
Do you have a history of schizophrenia, bipolar type 1 and 2 disorder or have experienced psychosis?
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