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Medical Cannabis Pre-Consultation Questionnaire
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Current Date
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Google Drive URLs
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Pain PDF
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Anxiety PDF
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Depression PDF
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Insomnia PDF
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All field PDF
Data Protection Disclosures and Consents
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Doctors Express is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below.
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Agreement to Data Processing
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In order to provide you the content requested, we need to store and process your personal data in accordance with our
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Personal Info
Name
*
First
Middle
Last
Date of Birth
*
DD dash MM dash YYYY
Email
*
Enter Email
Confirm Email
Phone Number
Medical History
For what medical condition(s) are you seeking treatment?
*
Select all that apply
pain
anxiety
depression
insomnia
other
Specify medical condition:
*
Have you previously been issued a medical cannabis identification card in any jurisdiction?
Yes
No
Please upload a copy (if available)
Accepted file types: jpg, gif, png, pdf, Max. file size: 15 MB.
Have you been diagnosed with, or treated for, this condition before?
*
Yes
No
Is there a family history of any medical conditions that may be relevant to your current condition
*
Yes
No
Specify family history:
*
What other treatment(s) have you tried for this condition?
*
Over the counter medications
Prescription medications
Physiotherapy
Chiropractic
Alternative treatments (e.g. acupuncture, dry needling)
Psychological management
Topical creams and ointments
I have not tried any other treatments
What were the results of these treatment(s) on your condition?
*
Much Better
Somewhat Better
About the Same
Somewhat Worse
Much Worse
Do you have any other chronic medical conditions?
*
Yes
No
Specify other chronic medical conditions:
*
Are you currently taking?
*
medications
supplements
herbal remedies
none of the above
List what you're currently taking:
*
Allergies and Contraindications
Do you have any known allergies to cannabis or any related plants (e.g. ragweed, sunflower)
*
Yes
No
Please specify
*
Allergies and Contraindications
Do you have a history of heart disease, lung disease or respiratory issues?
*
Yes
No
Specify history of heart/pulmonary issues:
*
Allergies and Contraindications
Are you pregnant, breastfeeding or planning to become pregnant?
*
Yes
No
Allergies and Contraindications
Have you had any recent surgeries or medical procedures?
*
Yes
No
Specify recent surgeries/medical procedures:
*
Allergies and Contraindications
Are you taking any of the following medications that may interact with cannabis?
Yes
No
Antidepressants — such as Zoloft, Prozac and Lexapro.
Pain medications — such as codeine, Percocet and Vicodin.
Anticonvulsants (seizure medications) — such as Tegretol, Topamax and Depakene.
Anticoagulants (blood thinners) — such as Coumadin, Plavix and heparin
Specify medications that may interact:
*
Psychiatric and Psychological History
Have you ever been diagnosed with or treated for any mental health conditions (e.g. anxiety, depression, psychosis)
*
Yes
No
Please specify
*
Are you currently using any medications or therapies for mental health?
*
Yes
No
Specify mental health medications/therapies you're currently using:
*
Substance Use History
Do you have a history of substance abuse or addiction (including alcohol or other drugs)?
*
Yes
No
Substance Use History
Have you used cannabis previously?
*
Yes
No
In what form did you previously use cannabis?
*
Smoked
Vaped
Edible
Topical
Oral/sublingual
Did your cannabis use help your symptoms?
*
Yes
No
What cannabis dosage has been most effective at managing your symptoms?
*
Include information on effective strains (e.g. indica/sativa) and THC/CBD dosing (if known)
Have you experienced any interactions between cannabis and other medications in the past?
*
Yes
No
Current Symptoms
Describe your current symptoms and how they impact your daily life
*
Current Symptoms
Are your symptoms chronic or intermittent?
*
Chronic - effects are persistent or otherwise long-lasting
Intermittent - the symptoms occur at irregular intervals
Treatment Goals
What are your treatment goals for using medical cannabis?
*
Routes of Administration
Do you have a preferred method of administration?
Vaporisable
Oral/Sublingual
No preference
PSYCHOLOGICAL SYMPTOMS SCORE SHEET
Over the last two weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it’s hard to sit still
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid as if something awful might happen
Not at all
Several days
More than half the days
Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
INSOMNIA
Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).
Difficulty falling asleep
None
Mild
Moderate
Severe
Very severe
Difficulty staying asleep
None
Mild
Moderate
Severe
Very severe
Problem waking up too early
None
Mild
Moderate
Severe
Very severe
How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
Very Satisfied
Satisfied
Moderately Satisfied
Dissatisfied
Very Dissatisfied
How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
Not at all Noticeable
A Little
Somewhat
Much
Very Much Noticeable
How WORRIED/DISTRESSED are you about your current sleep problem?
Not at all Worried
A Little
Somewhat
Much
Very Much Worried
To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?
Not at all Interfering
A Little
Somewhat
Much
Very Much Interfering
Brief Pain Inventory
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Time
Hours
:
Minutes
AM
PM
AM/PM
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these everyday kinds of pain today?
Yes
No
On the diagram, shade in the areas where you feel pain. Click on the area that hurts the most.
Clear
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Image url
Please rate your pain by selecting the number that best describes your pain at its worst in the last 24 hours.
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst pain imaginable
Please rate your pain by selecting the number that best describes your pain at its least in the last 24 hours.
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst pain imaginable
Please rate your pain by selecting the number that best describes your pain on the average.
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst pain imaginable
Please rate your pain by selecting the number that tells how much pain you have right now.
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst pain imaginable
What treatments or medications are you receiving for your pain?
In the last 24 hours, how much relief have pain treatments or medications provided?
0% No relief
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% Complete relief
Select the number that describes how, during the past 24 hours, pain has interfered with your:
General activity
0 Does not interfere
1
2
3
4
5
6
7
8
9
10 Completely interferes
Mood
0 Does not interfere
1
2
3
4
5
6
7
8
9
10 Completely interferes
Walking ability
0 Does not interfere
1
2
3
4
5
6
7
8
9
10 Completely interferes
Normal work (includes both work outside the home and housework)
0 Does not interfere
1
2
3
4
5
6
7
8
9
10 Completely interferes
Relationships with other people
0 Does not interfere
1
2
3
4
5
6
7
8
9
10 Completely interferes
Sleep
0 Does not interfere
1
2
3
4
5
6
7
8
9
10 Completely interferes
Enjoyment of life
0 Does not interfere
1
2
3
4
5
6
7
8
9
10 Completely interferes
DEPRESSION SYMPTOMS SCORE SHEET
Over the last two weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things
Not at all
Several Days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several Days
More than half the days
Nearly every day
Trouble falling or staying asleep, sleeping too much
Not at all
Several Days
More than half the days
Nearly every day
Feeling tired or having little energy
Not at all
Several Days
More than half the days
Nearly every day
Poor appetite or overeating
Not at all
Several Days
More than half the days
Nearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Not at all
Several Days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several Days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
Not at all
Several Days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
Not at all
Several Days
More than half the days
Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?
Not difficult At all
Somewhat difficult
Very difficult
Extremely difficult
Are you over 18 years of age?
Yes
No
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