Blue Grass Relief Clinic, LLC Patient Questionnaire

Chronic pain (chronic, severe, or debilitating pain)?*

Post-Traumatic Stress Disorder (PTSD)?*

Any type of cancer?*

Epilepsy?*

Glaucoma?*

Multiple sclerosis?*

Chronic or cyclical nausea?*

Seizure disorder?*

Do you have documentation of the diagnosis for any of the conditions listed above?*

If you do not have documentation for your chronic pain or PTSD diagnosis, would you like to schedule a separate appointment with a provider to be evaluated for these conditions? (This is a completely separate appointment, and there is an additional charge*