Altuva Patient Intake

Altuva Secure Intake

Please complete the online intake as accurately as possible
Name*
Phone number*
Date of birth*

DayMonthYear
Address*
Email (please enter in each box)*

Confirmation Email
Sex at birth*

FemaleMaleOther
Prounouns
How did you hear about the clinic?
Were you referred by a friend?*

YesNo
Referrer's Name
Referrer's Phone Number
Medicare Number*
Expiry Date (mm/yy)*
Individual Reference Number (IRN)*
The number next to your name on the medicare card
Do you have a concession card?*

YesNo
Concession card number
What form of cannabis are you interested in?*

THCCBDBothNot Sure
Have you used cannabis before?*

NoYes
Do you smoke cigarettes?*

NoYes
Do you drink alcohol?*

NoYes
Do you have a family doctor?*

NoYes
If yes, please provide a name and phone number
Are you seeing a specialist?*

NoYes
If yes, please provide a name and phone number
Have you ever been prescribed medicinal cannabis?*

NoYes
If yes, which clinic prescribed it?
Please provide the name of the clinic where your prescription was issued.
What is you primary medical condition?*

Alzheimer's DiseaseAnorexiaAnxietyADHDAutism Spectrum Disorder (ASD)CachexiaCancer SymptomsChemotherapy Induced NauseaChronic PainCrohn's DiseaseDementiaDepressionEndometriosisEpilepsyIBD and/or IBSInsomniaMood DisorderMultiple SclerosisNeuropathic PainOsteoarthritisPalliative CareParkinson's DiseasePTSDSeizure ManagementSleep DisorderSpasticityOther
My condition affects my daily routine*

NeverRarelySometimesFrequentlyAlways
My condition affects my ability to work*

NeverRarelySometimesFrequentlyAlways
Please list your current medications*
Please list your drug allergies*
What other therapies have you tried?*
You must have tried other therapies in order to be eligible for a cannabis prescription
Have you been diagnosed with a dependence on any drugs, prescribed or otherwise?*

NoYes
Have you ever experienced psychosis?*

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

NoYes
Has a close family member suffered from a psychotic illness?*

NoYes
Do you suffer from heart disease?*

NoYes
Are you pregnant or breastfeeding?*

NoYes
Are you subject to a parole or corrections order?*

NoYes
Have you been admitted to hospital in the past 6 months?*

NoYes
What are your treatment goals?*

Reduce painImprove functioningIncrease appetiteImprove moodImprove sleepOther
Patient Consent

I hereby confirm by signing below that I understand and have: a) completed the intake questions truthfully and to the best of my ability; b) discussed all questions and concerns about medical cannabis with my GP; c) taken sufficient time to understand how to use medical cannabis safely; c) read and understand the Patient Consent Form; d) that efficacy and effectiveness of cannabis are unknown; e) agree to use medical cannabis despite it not being registered or approved by the TGA; f) I can discontinue treatment with medical cannabis at any time and it is my decision to make; and g) provided my consent for Altuva to collect medical information to be openly discussed with relevant parties involved in my treatment. I agree that should I choose to electronically sign my name indicating my consent through Altuva, this is the legally binding equivalent to my handwritten signature. This electronic signature has the same meaning as my handwritten signature. I will not, at any time, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Signature

Clear
Notes
Should be Empty: