medical cannabis patient form

Date

name

Gender

male

female

Birth date -year

if the patient is a minor

Parent name

Are there any Allergies

Yes

No

Allergy in details

please write in CAPS LOCK

Medical diagnoses

triglycerides

Cholesterol LDL

Cholesterol HDL

HbA1C last one

indication for Cannabis treatment

Other

Please check all the patient's symptoms now

Symptoms now

	Irrelevant	Never	Rarely	From time to time	Often	All the time
self harm	Irrelevant	Never	Rarely	From time to time	Often	All the time
Problem with verbal communication	Irrelevant	Never	Rarely	From time to time	Often	All the time
Problem with nonverbal communication	Irrelevant	Never	Rarely	From time to time	Often	All the time
rage attacks	Irrelevant	Never	Rarely	From time to time	Often	All the time
Lack of cooperation	Irrelevant	Never	Rarely	From time to time	Often	All the time
Sensory regulation disorder	Irrelevant	Never	Rarely	From time to time	Often	All the time
Repetition in action or speech	Irrelevant	Never	Rarely	From time to time	Often	All the time
Seizures	Irrelevant	Never	Rarely	From time to time	Often	All the time
Selective eating	Irrelevant	Never	Rarely	From time to time	Often	All the time
Increase in appetite	Irrelevant	Never	Rarely	From time to time	Often	All the time
Decreased appetite	Irrelevant	Never	Rarely	From time to time	Often	All the time
Weight gain	Irrelevant	Never	Rarely	From time to time	Often	All the time
Weight loss	Irrelevant	Never	Rarely	From time to time	Often	All the time
Nausea	Irrelevant	Never	Rarely	From time to time	Often	All the time
Vomiting	Irrelevant	Never	Rarely	From time to time	Often	All the time
diarrhea	Irrelevant	Never	Rarely	From time to time	Often	All the time
constipation	Irrelevant	Never	Rarely	From time to time	Often	All the time
Abdominal pain	Irrelevant	Never	Rarely	From time to time	Often	All the time
Headaches	Irrelevant	Never	Rarely	From time to time	Often	All the time
back pain	Irrelevant	Never	Rarely	From time to time	Often	All the time
Joint pain	Irrelevant	Never	Rarely	From time to time	Often	All the time
Neuropathic pain	Irrelevant	Never	Rarely	From time to time	Often	All the time
Pain from another source	Irrelevant	Never	Rarely	From time to time	Often	All the time
depression	Irrelevant	Never	Rarely	From time to time	Often	All the time
anxiety	Irrelevant	Never	Rarely	From time to time	Often	All the time
Muscle stiffness	Irrelevant	Never	Rarely	From time to time	Often	All the time
Difficulties falling asleep	Irrelevant	Never	Rarely	From time to time	Often	All the time
Noninterrupted sleep	Irrelevant	Never	Rarely	From time to time	Often	All the time
Multiple winks	Irrelevant	Never	Rarely	From time to time	Often	All the time
Sleep is not refreshing	Irrelevant	Never	Rarely	From time to time	Often	All the time

Please specify habits such as: drinking alcohol, consuming drugs and smoking tobacco

Alcohol use

never

From time to time

Often

Every day

Smoking tobacco

Yes

No

From time to time

The average number of cigarettes per day (tobacco)

number of years of tobacco consumption (smoking)

Expectations treated from cannabis treatment

Do you get prescription drugs or vitamins in addition to cannabis?

Yes - on a regular basis

Yes occasionally

Not taking any drugs in addition to cannabis

Please with dosing and in CAPS LOCK

Regular medications

Not drugs, but physical therapy, support groups, psychotherapy and more

Do you get additional treatments?

Yes

No

Details: If you get additional treatments

Profession / occupation of the patient

Does not work

Student

volunteer

Part-time employee

Full time employee

Exercise

Never

once a week

twice a week

Over 3 times a week

Was there any previous experience with cannabis?

Yes

No

If there was a previous bad / good experience in cannabis

Monthly dose in gram

Please specify including percentages of active ingredients (CBD, THC)

The name of product (s) a user is using

Cannabis consumption method

smoking

Evaporation

Oil under the tongue

swallowing -Oil

Apply on the skin

times per day for cannabis consumption

Number of inhalation per use

number of drops of oil per use

Please note in a few words a general impression

Concluding remarks

Only if you wish you may fill your email

email