Health Questionnaire

Please complete the form below

Name *

Gender *

Male
Female

Are you pregnant? *

Yes
No

Are you breast feeding? *

Yes
No

Do you have personally or 1st degree family history of Schizophrenia or Psychosis *

Yes
No

Are you currently using Marijuana (except prescribed medicinal marijuana) or other recreational drugs? *

Yes
No

Date of birth *

Street address *

Suburb *

City *

Post code *

Mobile *

Email *

Other conditions you are suffering from? *

Do you have *

Heart condition
Diabetes
None of above

Any other medical or mental health conditions? *

Do you *

Smoke
Drink alcohol
Take Marijuana or other recreational drugs
None of above

Have you ever tried medicinal cannabis and in what form and for what reason *

What medications are you currently taking? *

Are you allergic to any anything / medications / other? *

What is your expectation from taking medicinal cannabis eg Relieve pain / Manage anxiety, etc *

By submitting this form, I declare that all information I have provided is true and I give informed consent with an appointment with the Doctor, who will advise me and prescribe Medicinal Marijuana as appropriate to manage my condition. I acknowledge that the Doctor is not obliged to prescribe if not appropriate *

Yes

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