Brain Fog and Marijuana Use - Anonymous Questionnaire

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* 1. Have you recently stopped using marijuana after a period of regular use?

Yes

No, I'm still using marijuana

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* 2. Please describe the symptoms you are experiencing

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* 3. When did the symptoms begin to appear?

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* 4. Have you experienced any of the following?

	None	Mild	Moderate	Quite a Lot	Severe
Forgetful	Forgetful None	Forgetful Mild	Forgetful Moderate	Forgetful Quite a Lot	Forgetful Severe
Difficulty thinking	Difficulty thinking None	Difficulty thinking Mild	Difficulty thinking Moderate	Difficulty thinking Quite a Lot	Difficulty thinking Severe
Difficulty focusing	Difficulty focusing None	Difficulty focusing Mild	Difficulty focusing Moderate	Difficulty focusing Quite a Lot	Difficulty focusing Severe
Difficulty speaking	Difficulty speaking None	Difficulty speaking Mild	Difficulty speaking Moderate	Difficulty speaking Quite a Lot	Difficulty speaking Severe
Difficulty processing what others say	Difficulty processing what others say None	Difficulty processing what others say Mild	Difficulty processing what others say Moderate	Difficulty processing what others say Quite a Lot	Difficulty processing what others say Severe
Difficulty processing words read	Difficulty processing words read None	Difficulty processing words read Mild	Difficulty processing words read Moderate	Difficulty processing words read Quite a Lot	Difficulty processing words read Severe
Confusion	Confusion None	Confusion Mild	Confusion Moderate	Confusion Quite a Lot	Confusion Severe
Fatigue	Fatigue None	Fatigue Mild	Fatigue Moderate	Fatigue Quite a Lot	Fatigue Severe
Thoughts moving too quickly	Thoughts moving too quickly None	Thoughts moving too quickly Mild	Thoughts moving too quickly Moderate	Thoughts moving too quickly Quite a Lot	Thoughts moving too quickly Severe

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* 5. How much of your day is impacted by brain fog?

Less than an hour a day

A few hours each day

Most of the day

All day

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* 6. When is your brain fog most severe?

Morning

Afternoon

Evening

Night

No pattern

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* 7. Are any daily activities disrupted by your brain fog?

Work productivity

Work motivation

Social activities

Schoolwork

None of the above

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* 8. Have you experienced any recent difficulty falling or staying asleep?

Yes

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* 9. What is your gender?

Female

Male

Other (specify)

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* 10. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 11. How long have you been using marijuana? (Please select the closest estimate.)

0-6 months

7-12 months

1-2 years

3-5 years

6-10 years

11+ years

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* 12. In the past year, how frequently have you used marijuana on average?

Multiple times a day

Once a day

Four to six times per week

Two to three times per week

One time per week

Two to three times per month

One time per month

Seven to eleven times this year

Three to six times this year

One to two times this year

I have used marijuana but not in the past year

I have never used marijuana

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* 13. In the past 60 days, how frequently have you used marijuana?

Multiple times a day

Once a day

Four to six times per week

Two to three times per week

One time per week

Two to three times per month

One time per month

One time in the past 60 days

I have not used marijuana in the past 60 days

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* 14. How much marijuana do you use in an average a day?

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* 15. For what purpose do you use marijuana?

Medicinal purposes only

Recreational purposes only

Both recreational and medicinal purposes

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* 16. How available is marijuana to you if you want to get it?

Readily available; I can get marijuana any time I want it.

Somewhat available; I can usually get marijuana when I want it, but sometimes it

Can be difficult.

Slightly available; I can sometimes get marijuana when I want it, but usually it is difficult.

Not very available; it is very difficult for me to get marijuana when I want it.

Not at all available; it is impossible to get marijuana.

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* 17. In what country do you live?

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* 18. Can we share your responses with our community (anonymously?)

Yes

No, I'd prefer it stay private

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* 19. Optional: Enter your email address to receive information about products we're developing to reduce withdrawal symptoms when quitting weed (we promise not to SPAM you).