GVW Application Form

  • Personal Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Are you Veteran?*
  • Will you be applying to Health Canada for your ACMPR license ("grow license")?*
  • Are you a First Responder?*

  • Patient Medical Information

    Please feel free to include any medical documentation or other supporting document for your medical diagnosis.
  • Do you plan on going to multiple Licensed Producers?*

  • PATIENT ASSESSMENT

  • What symptoms apply to your current medical condition(s)?

    *Please check all the boxes related to what you experience due to your medical condition(s)
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  • Brief Pain Inventory

    This is only for physical pain. You do not have to answer these questions if you do not have physical pain.
  • 1. Pain from time to time occurs (for example headaches, toothaches, sprains, etc). Have you experienced everyday pain not related to these common everyday pains?*
  • 7. In the last 24hrs, using medication or treatment how much relief have you experienced? (0% to be No Relief, 100% to be Complete Relief)*

  • 8. Please rate how your pain affects the following in the 24hrs. (0 to be minimum, 10 to be maximum)

  • 9. In the area where you experience pain, do you have the sensation of 'pins and needle', tingling, prickling or any similar sensation?*
  • 10. Does the area you experience pain change in color (mottled, redness, etc.) when the pain is bad?*
  • 11. Does the pain you experience make the skin feel abnormally sensitive ?
  • 12. Does the pain you experience come in bursts when you are completely still ?
  • 13. Does the pain you experience feel hot or feel as if the skin is burning?
  • 14. Gently rub the painful area and an area where you do not feel pain. How does the rubbing feel in the area of pain?
  • 15. Gently press on the area where you experience pain. How does this feel?

  • Generalized Anxiety Disorder 7-item (GAD-7) scale

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  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

  • Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.

  • Medical Cannabis Assessment

  • Do you use marijuana for relief?*
  • Do you smoke tobacco?*
  • Do you use medicines containing opiates (Codeine, morphine, other)?*
  • Are you allergic to any medicine?*
  • Do any of your family members suffer from psychiatric disorders?*
  • Is your father alive?
  • In good health?
  • Is your mother alive?
  • In good health?
  • Do you have siblings?

  • Psychological History

  • Do you suffer from
  • Have you been hospitalized for any of these illnesses?
  • Have you had any thoughts of self-harm or suicide?*
  • Are you often confused?

  • Review of Systems

  • Do you have any problems with senses (smell, taste, sight, hearing or touch)?*
  • Do you have any problems with your head or neck?*
  • Do you have any problems with breathing or lung diseases?*
  • Do you have heart or circulation problems?*
  • Have you ever had a heart attack?*
  • Do you problem climbing stairs or exercising?*
  • Do you have any eating, swallowing, digestion or problems with bowels?*
  • Do you have any problems with your kidneys, bladder or urination?*
  • Pregnancy: Are you pregnant now or might you become pregnant in the near future?*
  • Do you have problems with your muscles and joints?*
  • Do you have swelling anywhere?*

  • CAGE QUESTIONNAIR

  • 1) Have you ever felt you should cut down on your drinking?*
  • 2) Have people annoyed you by criticizing your drinking?*
  • 3) Have you ever felt bad or guilty about your drinking?*
  • 4) Have you ever had a drink first think in the morning to steady your nerves or get rid of a hangover (eye-opener)?*

  • Please list any medication you are taking:

    Info from home medication list as identified from intake history, patient, family, prescription bottle
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  • SOCIAL HISTORY

  • Marital Status:
  • Residential Status:

  • Patient Health Questionnaire (PHQ-9)

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  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
  • Date of Birth
     - -

  • Patient Consent to Disclose Information

  • I,   *   *   , hereby acknowledge that all the information provided by me is truthful and does not contain any information that might mislead the process.

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