Generate Prescription Subject *Patient's Name *Your Email ID *Phone Number *Address Please enter your addressPresent Illness (How did it start , duration etc.) *Upload existing prescription (Size should not be more than 2 MB) *For Cannabis based medicines, proof for disease diagnosis (i.e. Doctor's prescription, report) is mandatoryHistory of past illness (if any) Family History (Does any of your blood relation suffer from similar illness) Family HistoryDrug History ( Do you use any drug, alcohol or tobacco habitually ) *Drug HistoryAge *Sex *MaleFemaleMarital Status MarriedUnmarriedHeart Rate Blood Pressure (in mmHg) *Height (in feet and inches) Weight (in kilograms) *Blood sugar (in gm/dl) Profession Rate your sleep on the scall 1 to 5 Rate your sleep on the scall 1 to 5 12345Bowel habit Bowel habitDryHardPasteProperUrine YellowishPale YellowPainful urinationBurning urinationSleep Habit Sleep HabitdisturbeddeepdelayedDo you dream Do you dreamlots of dreamno dreammoderateAppetite *VariableExcesiveUnbreakableSlow but SteadyDiet habits *Diet habitsVegetarianNon-vegetarianMixedThrist *VariableExcessiveScantyDo you have any experience of using cannabis in any form? Are you allergic to any drug, antibiotic or any other supplement? *Current Medication, If any Submit RequestReset Request Check your Existing Request Powered by WSDesk Confidentiality Notice: All information in this personal Health Care Record is strictly confidential, that is legally privileged.