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2 for 1 Patient Intake Form
Tony
2020-01-08T06:12:47+00:00
Patient Intake Form 2 for 1 deal
Step 1 of 5 - Enter Details for the 2 for 1 Deal
20%
Your Name Name
First
Last
Name of the person who made the payment
*
First
Last
This is a 2 for 1 deal, let us know who made the payment.
What is your mailing address?
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Current Address
*
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
How many plants are you looking for ? (grams per day):
*
10 grams per day – $300 (49 Indoor plants, or 19 Outdoor plants)
20 grams per day = $400 (98 Indoor plants, or 38 Outdoor plants)
30 grams per day = $600 (146 Indoor plants, or 57 Outdoor plants)
40 grams per day = $700 (195 plants indoors or 76 Outdoor plants)
50 grams per day = $800 (244 Indoor plants, or 95 Outdoor plants) Best Seller
60 grams per day = $1000 (292 Indoor plants, or 114 Outdoor plants)
70 grams per day = $1200 (341 Indoor plants, or 133 Outdoor plants)
80 grams per day = $1500 (390 Indoor plants, or 152 Outdoor plants)
Email
Phone
What is your birth date?
*
DD
MM
YYYY
Please note you must be 21 years or older for us to give you a prescription.
What is your Skype ID or email you used to create your Skype account?
If you don't have an account please visit www.skype.com to register (phone or computer).
Is the address above the same as your mailing address?
*
Yes
No
How did you hear about us?
*
Facebook
Google Search
Third Choice
A friend
Other
Main problem(s) for which medical cannabis is being requested:
*
List all your current medications including dosage:
*
List any medications you are allergic to:
*
Do you use cocaine or other “street” drugs?
*
Yes
No
Please list any street drugs do you currently use and how often you use them:
*
Do any of your medications contain opiates? (Codeine, Morphine, etc.):
*
Yes
No
Do you currently use cannabis for relief?:
*
Yes
No
Please check all that apply:
vapor
edible
topical
smoke
Please list desired number of grams per day:
*
How often do you use cannabis?:
*
Everyday
Every other day
1-2 times per week
Once per week
Other
How often do you intake cannabis?:
*
Have you ever experienced an unpleasant /unwanted side effect of marijuana?:
*
Yes
No
Please describe your side effect:
*
Are you aware of the possible side effects that may occur from use of marijuana?:
*
Yes
No
Do you currently hold a prescription for medical cannabis?:
Yes
No
How many grams do you currently have a prescription for?:
*
Do you have or have you ever had any of the following medical conditions::
*
Please check all that apply
Asthma/Lung Disease
Hepatitis
Stroke
Kidney Disease
Thyroid
Heart Disease
Cancer
ADD/ ADHD
Substance Abuse
Depression
MS
Schizophrenia
Hyper Tension
No, I have not had any of these
List the name, last date seen and type of health care provider (doctor, chiropractor, therapist, psychologist, counselor, specialist or other (please specify) that you consult for your medical condition(s):
(Optional)
Have you had any prior surgeries?
Do you currently use tobacco products?
*
Yes
No
How often do you use tobacco per week?
*
Do you consume alcohol?
*
Yes
No
How often do you drink alcohol per week?
*
Please add any notes you feel are of importance:
(Optional )
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
Which area do you feel pain the most?
*
Head
Arms
Legs
Back
Neck
Knees
Elbows
Please rate your pain by checking the one number that best describes your pain at its worst in the past 24 hours:
*
1 - no pain
2
3
4
5 - a lot of pain
Please rate your pain by checking the one number that best describes your pain on average:
*
1 - no pain
2
3
4
5 - a lot of pain
Please rate your pain by checking the one number that best describes how much pain you have right now:
*
1 - no pain
2
3
4
5 - a lot of pain
In the past 24 hours, how much relief have pain treatments or medications provided? Please check the one percentage that most shows how much relief you have received:
*
0% - no pain
25%
50% - medium pain
75%
100% - a lot of pain
In the past 24 hours how much has pain interfered with your general activity?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your mood?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your walking ability?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your work?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your relationships with other people?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your sleep?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your enjoyment of life?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your ability to concentrate?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your appetite?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the area where you have pain, do you have “pins and needles”, tingling or prickling sensations?
*
Yes
No
Does the painful area change colour (perhaps mottled or red) when the pain is particularly bad?
*
Yes
No
Does your pain make the affected skin abnormally sensitive to the touch?
*
Yes
No
Does your pain come on suddenly and in bursts for no apparent reason when you are completely still?
*
Yes
No
In the area where you have pain, does your skin feel unusually hot like burning pain?
*
Yes
No
Gently rub the painful area with your index finger and then rub a non-painful area. How does the rubbing feel in the painful area?
*
No difference
Discomfort – pins and needles, tingling or burning in the painful area
Gently press on the painful area with your fingertip then gently press in the same way to a non painful area. How does this feel in the painful area?
*
No difference
Discomfort – pins and needles, tingling or burning in the painful area
I wake early and then sleep badly for the rest of the night:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I get very frightened or have panicked feelings for apparently no reason at all:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel miserable and sad:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel anxious when I go out of the house on my own:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I have lost interest in things:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I get palpitations, or sensations of “butterflies” in my stomach or chest:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I have a good appetite:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel scared or frightened:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel life is not worth living:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I still enjoy the things I used to:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I am restless and can't keep still:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I am more irritable than usual:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel as if I have slowed down:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
Worrying thoughts constantly go through my mind:
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
Upload a clear photo of your drivers licence or any form of ID
*
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*
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