Do you qualify for medical marijuana? Order Number Page 1 of 4 Have you been diagnosed with any of the following 21 qualifying conditions? * Acquired immune deficiency syndrome Alzheimer's disease Amyotrophic lateral sclerosis Cancer Chronic traumatic encephalopathy Crohn's disease Epilepsy or another seizure disorder Fibromyalgia Glaucoma Hepatitis C Inflammatory bowel disease Multiple sclerosis Pain that is either of the following: Chronic and severe; Intractable Parkinson's disease Positive status for HIV Post-traumatic stress disorder Sickle cell anemia Spinal cord disease or injury Tourette's syndrome Traumatic brain injury Ulcerative colitis No, I have not received a diagnosis of any of the conditions listed above Page 2 of 4 Are you an Ohio resident? * Yes No Do you have an Ohio driver's license? * Yes No Page 3 of 4 Is this recommendation for you? * Yes No Are you the caretaker of someone who needs a recommendation? * Yes No Page 4 of 4 Are you a veteran? * Yes No
