Massachusetts Patient Advocacy Alliance: Survey - Patients and medical professionals, tell your story

Patients and medical professionals, tell your story

1.

Please fill out the information below so we can contact you. (Please leave any questions blank if you're uncomfortable answering them.) We will keep your information confidential, sharing it only with those for whom you give us permission.


	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province:	State / Province: Required
*	ZIP / Postal Code: Required
	Phone Number:
	Remember me. What's this?

2.

Question - Not Required - Please indicate which conditions you suffer from or treat:

	HIV/AIDS
	Cancer/chemotherapy
	Glaucoma
	Multiple sclerosis
	Epilepsy/seizures
	Pain
	Multiple/other

3.

Question - Not Required - Please check all that apply:

	I am a patient.
	I am a family member/friend of a patient.
	I am a caregiver for a patient.
	I am a doctor.
	I am in a nurse.
	I am interested in writing letters to the editor.
	I am interested in speaking with the media.
	I am interested in testifying or speaking to legislators.

4.

Question - Not Required - Please tell us about how the medical use of marijuana could help or has helped you or a loved one.