Step 1 of 5 20% Patient Assessment FormFor Patients Seeking a Medical Cannabis DocumentGeneral DetailsFirst Name* Last Name* D.O.B.* MM slash DD slash YYYY Current Age* Gender* Male Female If female, are you pregnant or nursing? Yes No Healthcard # (Optional) Grams Per Day*- Select -5g @ $12010g @ $15015g @ $17520g @ $20030g @ $30040g @ $35050g @ $40060g @ $50070g @ $60080g @ $65095g @ $725Contact InformationAddress* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal code* Cell Phone*Email* Your Medical Condition and SymptomsPrimary Condition* Check off symptoms associated with your primary condition. Circle level of symptom severity. Level 1 - not severe, Level 5 - very severePain* 1 2 3 4 5 Muscle Spasms* 1 2 3 4 5 Mobility* 1 2 3 4 5 Headache* 1 2 3 4 5 Seizures* 1 2 3 4 5 Involuntary Movements* 1 2 3 4 5 Anxiety* 1 2 3 4 5 Depression* 1 2 3 4 5 Concentration/Focus* 1 2 3 4 5 Sleep Disturbance* 1 2 3 4 5 Visual Disturbance* 1 2 3 4 5 Weight Loss* 1 2 3 4 5 Lack of Appetite* 1 2 3 4 5 Nausea/Vomiting* 1 2 3 4 5 Low Energy* 1 2 3 4 5 Diarrhea* 1 2 3 4 5 Constipation* 1 2 3 4 5 Medication Side Effects* 1 2 3 4 5 What is your preferred method of taking cannabis?* Inhalation/Smoke Oral/Eat Topical/Cream Concentrates Juicing What are your treatment goals?* Reduce Pain Improve Daily Function Improve Appetite Improve Mood Improve Sleep Other Other Why is cannabis appropriate as a medical treatment?* How long have you been using cannabis?* Less than 1 year 1-2 years 3-5 years 6-10 years 10-20 years 20-35 years 35+ years Is cannabis your most effective medicine?* Yes No Has cannabis helped lower the dose of other prescription medications?* Yes No If yes then which medication(s)? Have you ever experienced any negative side effects?* Yes No If yes, please describe. Have you ever taken a break from cannabis?* Yes No If yes, what happened? Over the last 2 weeks, how often have you been bothered by any of the following problems? Select the most appropriate number for each.1. Little interest or pleasure in doing things* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 2. Feeling down, depressed, or hopeless* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 3. Trouble falling or staying asleep, or sleeping too much* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 4. Feeling tired or having little energy* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 5. Poor appetite or overeating* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 7. Trouble concentrating on things, such as reading the newspaper or watching television* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 8. Moving or speaking 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.* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 9. Thoughts that you would be better off dead or hurting yourself in some way* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 10. Feeling nervous, anxious, or on edge?* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 11. Not being able to stop or control worrying* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 12. Worrying too much about different things* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 13. Trouble relaxing* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 14. Being so restless that it’s hard to sit still* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15. Becoming easily annoyed or irritable* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 16. Feeling afraid* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day These questions refer to the past 12 months.Do you use drugs other than cannabis?* Yes No *** Attention Health Professional: By default, empty/blank fields means the user selected "NO" as their answer.***1. Have you used drugs other than those required for medical reasons? Yes No 2. Have you abused prescription drugs? Yes No 3. Do you abuse more than one drug at a time? Yes No 4. Can you get through the week without using drugs? Yes No 5. Are you always able to stop using drugs when you want to? Yes No 6. Have you had "blackouts"or "flashbacks" as a result or drug use? Yes No 7. Do you every feel bad or guilty about your drug use? Yes No 8. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No 9. Has drug abuse created problems between you and your spouse or your parents? Yes No 10. Have you lost friends because of your use of drugs? Yes No 11. Have you neglected your family because of your use of drugs? Yes No 12. Have you been in trouble at work (or school) because of drug abuse? Yes No 13. Have you lost your job because of drug abuse? Yes No 14. Have you gotten into fights when under the influence of drugs? Yes No 15. Have you engaged in illegal activities in order to obtain drugs? Yes No 16. Have you been arrested for possession of illegal drugs? Yes No 17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? Yes No 18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)? Yes No 19. Have you gone to anyone for help for drug problem? Yes No 20. Have you been involved in a treatment program specifically related to drug use? Yes No Brief Pain InventoryDo you use cannabis for pain?* Yes No *** Attention Health Professional: By default, empty/blank fields means the user selected "NO" as their answer.***1. 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 2. Please rate your pain by selecting the one number that best describes your pain at its worst in the past 24 hours. 0 1 2 3 4 5 3. Please rate your pain by selecting the one number that best describes your pain at its least in the last 24 hours. 0 1 2 3 4 5 4. Please rate your pain by selecting the one number that best describes your pain on average. 0 1 2 3 4 5 5. Please rate your pain by selecting the one number that tells how much pain you have right now. 0 1 2 3 4 5 6. What treatments or medications are you receiving for your pain? 7. In the past 24 hours, how much relief have pain treatments or medications provided? Please select the one percentage that most shows how much relief you have received. 0% 10% 20% 30% 40% 50% 8. Select the one number that describes how, during the past 24 hours, pain has interfered with your:A. General activity 0 1 2 3 4 5 B. Mood 0 1 2 3 4 5 C. Walking ability 0 1 2 3 4 5 D. Normal work (includes both work outside the home and housework) 0 1 2 3 4 5 E. Relations with other people 0 1 2 3 4 5 F. Sleep 0 1 2 3 4 5 G. Enjoyment of life 0 1 2 3 4 5 H. Ability to concentrate 0 1 2 3 4 5 I. Appetite 0 1 2 3 4 5 Patient Release FormTreatment Agreement between Health Professional and PatientI* I understand that this Release and Acknowledgment contains IMPORTANT information about medical cannabis that the assessing Health Professional requires that I acknowledge and understand before he/she may issue a prescription and/or authorization for the use of medical cannabis. I further understand that the consulting Health Professional will not necessarily be assuming care for me. He/She will, however, assess and evaluate the appropriateness of my request to use medical cannabis to assist in treating the conditions and associated symptoms that I believe; from my own personal experience, medical cannabis to be helpful in treating. I accordingly confirm that the assessing Health Professional will be my medical practitioner for the sole purpose of medical cannabis authorization and/or prescriptions. I agree not to make any claim or commence any legal proceedings against the assessing Health Professional, his/her practice, my family physician or any other involved Health Professionals (such as specialists) in relation to: My use of cannabis as a medicine; and My Application, or, prescription for possessing, obtaining, and using medical cannabis. I am well aware that Health Professionals generally agree that medical cannabis; May distort perception (sight, sounds, time, touch); May impair memory and learning May impair coordination (Avoid driving for 4 hours after smoking and 8 hours after ingesting) May impair thinking and problem-solving May increase heart rate and reduce blood pressure May produces anxiety, fear, distrust, or panic I am well aware there is considerable debate and a great lack of consensus among Health Professionals about: The appropriate medical use of cannabis The appropriate dosage for medical cannabis The risks of smoking medical cannabis as compared to vaporizing or ingesting medical cannabis The risks of smoking whole plant medical cannabis as compared to extracting the medicinally active cannabinoid and medicating with same The long-term health and psychological risks associated with the use of medical cannabis The degree to which regular consumption of medical cannabis: May contribute to pulmonary infections and respiratory cancer May damage the cells in bronchial passages which protect the body against inhaled microorganisms and decrease the ability of the immune cells in the lungs to fight off fungi, bacteria, and tumour cells. For patients with already weakened immune systems, this means an increase in the possibility of dangerous pulmonary infections, including pneumonia May weaken various natural immune mechanisms, including macrophages and T-cells May correlate in some cases with mental illness, such as bipolar disorder and schizophrenia I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products, I generally consume a medication of a precisely known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way. I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from strain of plant to strain of plant and even, to a lesser degree, from plant to plant of the same strain. I further appreciate that there is significant uncertainty regarding the consistency of the medical cannabis drug product I may medicate with which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis. I am further aware that ingesting a high dose of medical cannabis can cause nausea and disorientation. I am seeking medical cannabis treatment and I confirm I have consulted with a Health Professional regarding alternative and conventional treatment options for my condition. Despite all these medical concerns, debates and practical issues I honestly believe that for the treatment of my condition(s) and symptom(s) the benefits of medicating with medical cannabis outweigh the risks. I agree to receive a “medical document” (i.e. prescription) for medical marijuana only from one Health Professional. I agree to purchase my marijuana only from a Licensed Producer. I am aware that possession of marijuana from other sources is illegal. I agree to safely store my marijuana so that no other person can access it either deliberately or accidentally. I will ensure that no child or young person will be exposed to my medical marijuana either directly or indirectly. I will contact Poison Control immediately if any child gains access to my supply of medical marijuana. I am aware that taking marijuana with other substances, especially sedating substances, may cause harm and possibly even death. I will not use illegal drugs (e.g. cocaine, heroin) or controlled substances (e.g. narcotics, stimulants, anxiety pills) that were not prescribed for me. I will inform the Health Professional of all controlled substances that are prescribed to me by my regular Health Professional(s). I will inform my primary care Health Professional that I am being prescribed medical marijuana. I agree to have a medical assessment performed by my regular Health Professional at least every 12 months. I am aware that marijuana use is not advisable during pregnancy and breastfeeding. I agree to inform my Health Professional if I am pregnant. If I become pregnant while being treated with medical marijuana, I will immediately stop using it until I have consulted with a Health Professional. This is my decision, and I also do not support any claims made by my family, friends or other interested parties against said clinic and Health Professionals. I hereby release Cann Grow Consulting also known as 11520601 Canada Inc, the assessing Health Professional, his/her clinic, my family Health Professional, and any other involved Health Professionals from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to my use of medical cannabis and my Application to posses medical cannabis. This release from liability is to be binding on heirs, executors and assigns. I also consent to the disclosure, sharing and use of my personal information and medical data by the assessing Health Professional, Health Canada, Cann Grow Consulting also known as 11520601 Canada Inc and my Licensed Producer. The information may be used to contact, assess and register the patient and for analysis and research to better help our members. I understand and acknowledge that while the assessing Health Professional may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing Health Professional will not serve as my primary care Health Professional. As such I agree, to seek regular medical care from my primary care Health Professional and that the assessing Health Professional will only deal with assessing his/her support for my medical cannabis use. I also consent to the assessing Health Professional notifying any specialists that have seen of my decision to use medical cannabis, and I accept any consequences of such notification. I agree to notify my primary care Health Professional myself about my intent to use cannabis medicinally as cannabis can interact with other medications. If licensed, I agree not to resell or give away any of my medication. I agree to check with local bylaws in my area. I also agree that any legal actions will take place in Ontario and be governed by the laws of Ontario, Canada. I agree that Cann Grow Consulting also known as 11520601 Canada Inc assumes no responsibility for the outcome of my application with Health Canada. If Health Canada refuses my application with the reason of “requesting more information” I understand I will have two options. My practitioner may write a lower grams per day prescription (25g) at no cost My practitioner may advocate on my behalf to Health Canada. I understand this is not covered in the scope of the original appointment, and is a lengthy process that requires me to provide medical documents, and have my practitioner put together a case on my behalf. I understand there will be a fee of $150 for this. I agree to the following terms of cancellation and rescheduling. Appointments canceled prior to 48 hours before scheduled time will receive a full refund Appointments canceled less than 48 hours will receive no refund Missed appointment may be rescheduled for a fee of $50 + HST Damaged, lost or any other situation that requires a prescription to be resent will have a fee of $50 + HST Patient Signature*HiddenHealth Professional SignaturePatient Name* HiddenHealth Professional Name Date Signed* MM slash DD slash YYYY HiddenDate Signed MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ