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.
Contact Number*
Please enter a valid phone number.
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.
Gender*

MaleFemalePrefer not to say
Please Provide your Local GP *
Address Of Practice*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any chronic conditions (lasting 3 months or more) ?*

AsthmaCancerCardiovascular DiseaseDiabetesHypertensionEpilepsyChronic Pain (e.g. Arthritis)InflammationOther
Have you ever been prescribed psychotic or opiate based medicines ?*

YesNo
If yes please inform us what medication and duration ?
Have you ever or do you currently suffer from any of the following conditions?*

AnxietyDepressionObsessive Compulsive DisorderParanoiaPost Traumatic Stress DisorderPsychosisSchizophreniaThoughts of self harm/suicideNot ApplicableOther
Are you pregnant or breastfeeding?*

YesNoNot Applicable
Have you ever had Professional help? (Counselling, Therapy)*
If yes, how effective was the treatment?

Little to no impact on my wellbeingPositive impact on my wellbeingLasting changes to my wellbeing
Are you currently taking any medication?*

YesNo
If yes, what medication do you currently take?
Do you have any medication allergies?*

YesNoNot Sure
If yes, what are those allergies?
Have you ever been diagnosed with Substance Dependence?*

YesNo
Do you have thoughts of suicide/hurting yourself or others?*

YesNo
Has a close family member suffered from a mental illness?*

YesNo
Do you use or do you have history of using tobacco?*
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
How many drinks would you consume over a week?*

0-55-1010-1515+
What are the reasons you are seeking Alternative Medicines?*

AnxietyDepressionInsomniaPain managementImprove appetite due to Chronic IllnessOther
How do these reasons affect your quality of living?*

RarelySlightlyModeratelySeverely affected (e.g. struggle with day to day activities)
Is your ability to work affected due to these reasons?*

RarelySlightlyModeratelyFrequently
Do you use or do you have history of using Cannabis?*
How much cannabis do you consume per day*

0-1g2-5g5g+None
Preferred consumption method
Have you had any negative side effects after consuming cannabis?*

YesNoNot Applicable
If yes, what were the side effects?
Has cannabis helped with reducing the use of any medication or substance being taken? Including Alcohol*

YesNoNot Applicable
If yes, list the medications or substances
What are your treatment goals?*

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
Disclaimer*

I understand that the Doctor / Prescribers has the right to refuse treatment at their discretion
Signature*

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Patient Intake Form