Questionnaire – NEW

Patient Questionnaire

"*" indicates required fields

Which type of booking would you like to make?*

Legal First and Surname*

Email*

Gender*

Other Gender*

Full Address - Suburb/City/Postcode*

Full Date of Birth*

Contact number*

Doctor*

GP Clinic*

NHI (if known)

Do you suffer from any of the following conditions? Please Select

Heart Disease

Lung Disease

Diabetes

Phaeochromocytoma

Thyroid Disease

High Blood Pressure

Do you suffer from any of the following symptoms? Please Select

Headaches

Palpitations

Sweating

What is the main reason you're wanting medicinal cannabis? for eg pain/anxiety/sleep?*

Please list any medical conditions you have. Eg, Diabetes, Epilepsy, Anxiety etc

Please list any medications you are taking.

Are you allergic to any medications? (If so, please list them)*

Have you or anyone in your family ever been diagnosed with Schizophrenia?*

Have you or anyone in your family ever had a Psychotic episode?*

Are you pregnant?*

Are you breast feeding?*

Do you have a history of addiction or substance abuse?*

Do you use cannabis on a regular basis?*

Has cannabis use ever made you paranoid or psychotic?*

Have you ever used cannabis before?*

Do you smoke cigarettes?*

Do you drink alcohol?*

If so, how many standard drinks do you consume per week?*

Are you ok with us sending a copy of our clinical letter to your GP?*

How did you hear about us?*

Please note that if you cancel within 24 hours of your appointment or do not answer your phone for your consult you will NOT be eligible for a refund.*

Questionnaire – NEW

Patient Questionnaire

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