Please complete the questionnaire below.

    Client's First Name: (required)

    Client's Last Name: (required)

    Contact Number: (required)

    Your Email: (required)

    Your Age: (required)

    Any Symptoms or Complaints?

    Duration of Symptoms?

    How has it affected your day to day activities of daily living?

    How has it affected your Sleep?

    How has it affected your job?

    What CBD product(s) did you use? (choose from below)

    If other Product, List it here:

    Are you still using it /them?

    How much or how often did you use the product?

    What were the results?

    How long did it take for you to notice any results?

    How has the product (s) changed your life?

    Did you experience any Side Effects?

    If yes, what?

    Did you notice any other change, effect or improvements in any other aspect of your health?

    If yes, what?

    Any Additional Comments?


    YOU AGREE that by providing this information, YOU are authorizing its use for data collection, which may be used for promotional and educational purposes that may include publication. You understand that no client identifying information will be made public. Any contact information provided will be used solely to communicate with YOU if additional information is needed.

    We truly appreciate your participation and feedback!

    Thanks from GOT HEMP!
    Marchalee and Kurt

    Find out which CBD product is right for you.

    Scroll to Top