Patient assessment form

  • General Details

  • Contact Information

  • General Practitioner Information (optional)

  • Medical Condition and Symptoms

    Describe your primary condition for which you are seeking medical cannabis.
  • Symptoms

    For any symptoms associated with your primary condition select the level of symptom severity. Level 1 - Not Severe Level 5 - Very Severe
  • Mental Health

    Over the last 2 weeks, how often have you been bothered by any of the following problems? Select the most appropriate one for each.
  • Medical History

    If you currently are in possession of any of your medical records or any documentation from a health care professional describing your medical condition, please upload them on the Patient Assessment Form or scan and email them to us. If you do not have documentation currently, For a consultation with our Physician, we ask that you gather and send the following information to our office. PLEASE NOTE the Physician cannot diagnose you at the appointment, so your medical condition must be evidenced prior to and for the consultation. Please provide one or more of the following that would pertain to the same condition for which you are seeking cannabis: - From any Physician, Psychiatrist or Psychologist whom you have seen: your chart / clinical notes or a relevant consultation note (i.e: for employment / unemployment purposes) - From any Hospital and / or Specialist visit(s): reports, letters or summaries - Chiropractic or Physiotherapy assessment or summary - Imaging reports if applicable to your medical condition. You can ask your physician, or go directly where you had the tests/assessments done and ask for a copy. Please also provide from your physician list of prescriptions that you have taken for the condition you are seeking cannabis for. You can also retrieve a print-out called a Patient Profile from your pharmacy.
  • Allowed file types : .jpg, .pdf, .doc, .docx
  • Current Medications

    Include any and all medications used to treat the diagnosed medical condition or any other unrelated condition or symptoms. Please indicate the dosage of each.
  • Therapies

    If you have tried any of the following therapies select the level of effectiveness for each. Level 1 - Not Effective, Level 5 - Very Effective
  • Cannabis Use

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