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Medical Cannabis Pre-Consultation Questionnaire

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Data Protection Disclosures and Consents*
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*
In order to provide you the content requested, we need to store and process your personal data in accordance with our Privacy Policy. If you consent to this please tick the checkbox below.

Personal Info

Name*
DD dash MM dash YYYY
Email*

Medical History

For what medical condition(s) are you seeking treatment?*
Select all that apply
Have you previously been issued a medical cannabis identification card in any jurisdiction?
Accepted file types: jpg, gif, png, pdf, Max. file size: 15 MB.
Have you been diagnosed with, or treated for, this condition before?*
Is there a family history of any medical conditions that may be relevant to your current condition*
What other treatment(s) have you tried for this condition?*
What were the results of these treatment(s) on your condition?*
Do you have any other chronic medical conditions?*
Are you currently taking?*

Allergies and Contraindications

Do you have any known allergies to cannabis or any related plants (e.g. ragweed, sunflower)*

Allergies and Contraindications

Do you have a history of heart disease, lung disease or respiratory issues?*

Allergies and Contraindications

Are you pregnant, breastfeeding or planning to become pregnant?*

Allergies and Contraindications

Have you had any recent surgeries or medical procedures?*

Allergies and Contraindications

Are you taking any of the following medications that may interact with cannabis?
  • 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

Psychiatric and Psychological History

Have you ever been diagnosed with or treated for any mental health conditions (e.g. anxiety, depression, psychosis)*
Are you currently using any medications or therapies for mental health?*

Substance Use History

Do you have a history of substance abuse or addiction (including alcohol or other drugs)?*

Substance Use History

Have you used cannabis previously?*
In what form did you previously use cannabis?*
Did your cannabis use help 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?*

Current Symptoms

Current Symptoms

Are your symptoms chronic or intermittent?*

Treatment Goals

Routes of Administration

Do you have a preferred method of administration?

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 being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it’s hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
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?

INSOMNIA

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).
Difficulty falling asleep
Difficulty staying asleep
Problem waking up too early
How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
How WORRIED/DISTRESSED are you about your current sleep problem?
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?

Brief Pain Inventory

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Time
:
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?
On the diagram, shade in the areas where you feel pain. Click on the area that hurts the most.


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Please rate your pain by selecting the number that best describes your pain at its worst in the last 24 hours.
Please rate your pain by selecting the number that best describes your pain at its least in the last 24 hours.
Please rate your pain by selecting the number that best describes your pain on the average.
Please rate your pain by selecting the number that tells how much pain you have right now.
In the last 24 hours, how much relief have pain treatments or medications provided?
Select the number that describes how, during the past 24 hours, pain has interfered with your:
General activity
Mood
Walking ability
Normal work (includes both work outside the home and housework)
Relationships with other people
Sleep
Enjoyment of life

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
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thoughts that you would be better off dead or of hurting yourself in some way
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?

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