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MiniOV1

Identifying Information - Face Sheet

1. Your first name (legal name on drivers license)? *This question is required.

2. Your first name (nickname or preferred name)? *This question is required.

3. Your last name? *This question is required.

4. IDENTIFYING INFORMATION

Age

Street Address

Apt/Suite/Office

City

State

Zip

Sex (Gender) *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Phone Number *This question is required.

Handedness *This question is required.

Email Address *This question is required. This question requires a valid email address.

How tall are you?

How much do you weigh?

5. Work/Employment

6. Marital Status *This question is required.

Are you now or have you ever been in the military (Navy, Army, Marines etc)

7. What problem do you need to be evaluated for?" *This question is required.

Which Pharmacy?

9. What is the Address of that pharmacy? *This question is required.

10. Do you smoke cigarettes or vape nicotine? *This question is required.

11. Do you use Cannabis (weed, THC)?

How do you use Cannabis (route of administration)?

Space Cell	Flower, Weed	PreRoll	Vape (Vaporizer)	Dab (concentrate)	Edibles	Other
Every day	Every day: Flower, Weed	Every day: PreRoll	Every day: Vape (Vaporizer)	Every day: Dab (concentrate)	Every day: Edibles	Every day: Other
Most days	Most days: Flower, Weed	Most days: PreRoll	Most days: Vape (Vaporizer)	Most days: Dab (concentrate)	Most days: Edibles	Most days: Other
Once in a while	Once in a while: Flower, Weed	Once in a while: PreRoll	Once in a while: Vape (Vaporizer)	Once in a while: Dab (concentrate)	Once in a while: Edibles	Once in a while: Other
Never	Never: Flower, Weed	Never: PreRoll	Never: Vape (Vaporizer)	Never: Dab (concentrate)	Never: Edibles	Never: Other

12. Do you use Caffeine (coffee, tea, etc)?

How do you use caffeine (route of administration)?

Space Cell	Coffee	Espresso	Diet Soda (Pepsi, Diet Coke, Barqs, etc)	Energy Drinks (Red Bull, Monster etc)	Other
Every day	Every day: Coffee	Every day: Espresso	Every day: Diet Soda (Pepsi, Diet Coke, Barqs, etc)	Every day: Energy Drinks (Red Bull, Monster etc)	Every day: Other
Most days	Most days: Coffee	Most days: Espresso	Most days: Diet Soda (Pepsi, Diet Coke, Barqs, etc)	Most days: Energy Drinks (Red Bull, Monster etc)	Most days: Other
Once in a while	Once in a while: Coffee	Once in a while: Espresso	Once in a while: Diet Soda (Pepsi, Diet Coke, Barqs, etc)	Once in a while: Energy Drinks (Red Bull, Monster etc)	Once in a while: Other
Never	Never: Coffee	Never: Espresso	Never: Diet Soda (Pepsi, Diet Coke, Barqs, etc)	Never: Energy Drinks (Red Bull, Monster etc)	Never: Other

13. Do you Drink Alcohol (Beer, Wine, Distilled Liquor like Vodka, Whiskey, Brandy, Tequila, Gin, Rum, etc)?