Quality of Medicinal Cannabis Use Survey

Quality of Medicinal Cannabis Survey
Your Initials*

First InitialLast Initial
Gender*

MaleFemaleIndeterminate
Date of Birth*

DayMonthYear
Date of commencement of medicinal cannabis*

DayMonthYear
Date
Brand/s of medicinal cannabis*
(if you're using more than one brand, please seperate brands with a comma)
Strength of medicinal cannabis*
Dose*
(please enter the amount of your dose in ml)
Number of times taken per day*

1234Other
What is the primary condition that medicinal cannabis has been prescribed for?*

Chronic painCancerAnxietyMood disorderEpilepsyArthritisSleep disorderMultiple SclerosisParkinsonsInflammatory bowel disease

What is your average pain score between 0-10*

	0	1	2	3	4	5	6	7	8	9	10
Before commencing medicinal cannabis
After commencing medicinal cannabis

Please check the option that best describes the overall severity of the condition in the last 4 weeks*

MildModerateSevere
Was the medicinal cannabis prescribed by your/the patients doctor?*

YesNo
Were you/the patient prescribed more than one medicinal cannabis?*

YesNo
How much benefit do you expect to receive as a result of taking the prescribed medicinal cannabis product/s?*

No benefitMinimal benefitModerate benefitA great deal of a benefitUnsure
Do you expect any side effects as a result of taking the prescribed medicinal cannabis product/s?*

No, noneYes, mild side effectsYes, moderate side effectsYes, severe side effects

Have you experienced any of these known side effects?*

	Yes	No
Drowsiness/fatigue
Dizziness
Dry mouth
Cough, phlegm, bronchitis (smoking only)
Anxiety
Nausea
Cognitive effects
Euphori (feeling high)
Blurred vision
Headache
Feeling dizzy when you stand up
Toxic psychosis/paranoia
Deppression
Ataxia/ dyscoordination
Tachycardia (after titration)
Cannabis hyperemesis
Diarrhoea

How often has the prescription been taken*

Once dailyTwice dailyThree times dailyFour times dailyAs Required

Please select a number between 0 and 10 to rate the level of distress being caused by the following symptoms before commencing medicinal cannabis*

Please select a number between 0 and 10 to rate the level of distress being caused by the following activities before commencing medicinal cannabis*