"*" indicates required fields Hi Welcome back. Please fill in the form below and click submit when you are finished.User NameEmail 1. Syptoms of Primary Complaint*123456789100 = None 10 = Severe2. Level of Pain*123456789100 = None 10 = Severe3. Anxiety level*123456789100 = None 10 = Severe4. Quality of sleep*123456789100 = Terrible 10 = Excellent5. Mood*123456789100 = Terrible 10 = Excellent6. Energy Level*123456789100 = Very Low 10 = Very High7. Overall Health*123456789100 = Worst Imaginable 10 = Best Imaginable8. Over the past week, have you experienced any side effects ?*Please choosePlease selectNoneConcentration (better)Concentration (worse)CoughingDiarrheaDisorientationDizzinessDrowsinessDry MouthEuphoriaHeadachesIncreased Heart RateAppetite (more)Appetite (less)Memory (better)Memory (worse)NauseaNightmaresPanicVivid DreamsOtherOther - please specifyYour Current Medication*Please chooseOilFlowerVape cartEdiblesWafersPlease choose*Please ChooseLumir Gasoline Cream – GAS/CALumir Mint Sherbert – MSB/CAHigh Country KK MintsHigh Country L.A Kush CakeHelix T21Helox T25Please choose*Please ChooseLumir THC 25Lumir CBD 100 Full SpectrumLumir 12.5:12.5 BalancedLumir 25:25 BalancedPlease choose*Please ChooseHigh COountry OG Guava (day)High Country Berry Blue (night)Dosage (ml/day)*Dosage (puffs/day)*Dosage (grams/day)*Have you changed your dosage? Your journey matters SHARE YOUR EXPERIENCE WITH US Your journey matters SHARE YOUR EXPERIENCE WITH US POLICIES Contact Us EMAIL info@lumirmission.com SOCIAL
