Medical Cannabis Pre-Consultation Questionnaire "*" indicates required fields Step 1 of 20 5% HiddenCurrent Date YYYY slash MM slash DD HiddenGoogle Drive URLsHiddenPain PDF HiddenAnxiety PDF HiddenDepression PDF HiddenInsomnia PDF HiddenAll field PDF 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. You can unsubscribe from these communications at any time. For more information about our privacy policy and your rights, please read our Privacy Policy. I agree to receive other communications from Doctors Express.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. I agree to allow Doctors Express to store and process my personal data. Personal InfoName* First Middle Last Date of Birth* DD dash MM dash YYYY Email* Enter Email Confirm Email Medical HistoryFor 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 ContraindicationsDo you have any known allergies to cannabis or any related plants (e.g. ragweed, sunflower)* Yes No Please specify* Allergies and ContraindicationsDo you have a history of heart disease, lung disease or respiratory issues?* Yes No Specify history of heart/pulmonary issues:* Allergies and ContraindicationsAre you pregnant, breastfeeding or planning to become pregnant?* Yes No Allergies and ContraindicationsHave you had any recent surgeries or medical procedures?* Yes No Specify recent surgeries/medical procedures:* Allergies and ContraindicationsAre 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 HistoryHave 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 HistoryDo you have a history of substance abuse or addiction (including alcohol or other drugs)?* Yes No Substance Use HistoryHave 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 SymptomsDescribe your current symptoms and how they impact your daily life* Current SymptomsAre your symptoms chronic or intermittent?* Chronic - effects are persistent or otherwise long-lasting Intermittent - the symptoms occur at irregular intervals Treatment GoalsWhat are your treatment goals for using medical cannabis?* Routes of AdministrationDo you have a preferred method of administration? Vaporisable Oral/Sublingual No preference PSYCHOLOGICAL SYMPTOMS SCORE SHEETOver 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 INSOMNIAPlease 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 InventoryHiddenTime 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.[body_indetifier]HiddenImage 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 SHEETOver 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