Medical History Form

Patient Intake Form

Please fill out the form below to book a consult with a prescribing doctor.
Full Name*

First NameLast Name
Email*
example@example.com
Mobile Number
Please enter a valid phone number.Format: 0000 000 000.
Contact Number*
Please enter a valid phone number.Format: 0000 000 000.
Home Phone number (If no mobile)
Date Of Birth*

DayMonthYear
Date
Address*

Address

Street Address

CityState / Province

Postal / Zip Code
Emergency Contact Name*
Emergency Contact Number*
Relation with Emergency contact*
Medicare Number*
IRN (Number next to your name on Medicard)*
Medicard Expiry date (valid to)*
Please provide month and year as written on card.
MaleFemalePrefer not to say
Please Provide your Local GP *
Address Of Practice*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AsthmaCancerCardiovascular DiseaseDiabetesHypertensionEpilepsyChronic Pain (e.g. Arthritis)InflammationOther
YesNo
If yes please inform us what medication and duration ?
AnxietyDepressionObsessive Compulsive DisorderParanoiaPost Traumatic Stress DisorderPsychosisSchizophreniaThoughts of self harm/suicideNot ApplicableOther
YesNoNot Applicable
Have you ever had Professional help? (Counselling, Therapy)*
Little to no impact on my wellbeingPositive impact on my wellbeingLasting changes to my wellbeing
YesNo
If yes, what medication do you currently take?
YesNoNot Sure
If yes, what are those allergies?
YesNo
YesNo
YesNo
Do you use or do you have history of using tobacco?*
DailyWeeklyMonthlyOccasionallyNever
0-55-1010-1515+
AnxietyDepressionInsomniaPain managementImprove appetite due to Chronic IllnessOther
RarelySlightlyModeratelySeverely affected (e.g. struggle with day to day activities)
RarelySlightlyModeratelyFrequently
Do you use or do you have history of using Cannabis?*
0-1g2-5g5g+None
Preferred consumption method
YesNoNot Applicable
If yes, what were the side effects?
YesNoNot Applicable
If yes, list the medications or substances
Improve daily functioningImprove moodDecrease painIncrease appetite
Why do you think alternative medicines, like cannabis, can help your conditions?
I have completed the above patient intake form truthfully and to the best of my abilities and consent to this information being given to our staff for consult booking purposes

I have carefully read the terms and conditions and privacy policy
I understand that the Doctor / Prescribers has the right to refuse treatment at their discretion
Signature*
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Patient Intake Form