Quality of Medicinal Cannabis Survey
Your Initials
*
First Initial
Last Initial
Gender
*
Male
Female
Indeterminate
Date of Birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date of commencement of medicinal cannabis
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
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
*
1
2
3
4
Other
What is the primary condition that medicinal cannabis has been prescribed for?
*
Chronic pain
Cancer
Anxiety
Mood disorder
Epilepsy
Arthritis
Sleep disorder
Multiple Sclerosis
Parkinsons
Inflammatory bowel disease
What is your average pain score between 0-10
*
Rows
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
*
Mild
Moderate
Severe
Was the medicinal cannabis prescribed by your/the patients doctor?
*
Yes
No
Were you/the patient prescribed more than one medicinal cannabis?
*
Yes
No
How much benefit do you expect to receive as a result of taking the prescribed medicinal cannabis product/s?
*
No benefit
Minimal benefit
Moderate benefit
A great deal of a benefit
Unsure
Do you expect any side effects as a result of taking the prescribed medicinal cannabis product/s?
*
No, none
Yes, mild side effects
Yes, moderate side effects
Yes, severe side effects
Have you experienced any of these known side effects?
*
Rows
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 daily
Twice daily
Three times daily
Four times daily
As 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
*
Rows
0
1
2
3
4
5
6
7
8
9
10
Pain
Nausea
Sleep problems
Deppression
Please select a number between 0 and 10 to rate the level of distress being caused by the following activities before commencing medicinal cannabis
*
Rows
0
1
2
3
4
5
6
7
8
9
10
General activity
Walking ability
Mood
Work(including house work)
Relations with other people
Sleep
Enjoyment of life
Submit
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