Apply for Your Medical Cannabis Evaluation

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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

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

Medical Cannabis Pre-Consultation Questionnaire

Google Drive URLs

Personal Info

Medical History

Allergies and Contraindications

Allergies and Contraindications

Allergies and Contraindications

Allergies and Contraindications

Allergies and Contraindications

Psychiatric and Psychological History

Substance Use History

Substance Use History

Current Symptoms

Current Symptoms

Treatment Goals

Routes of Administration

PSYCHOLOGICAL SYMPTOMS SCORE SHEET

INSOMNIA

Brief Pain Inventory

DEPRESSION SYMPTOMS SCORE SHEET