Patient Assessment Form - Canna Heal Me

Patient Assessment Form

Welcome to the Canna-Health Medical Cannabis Group Inc. powered by Cannascribe Online. You are about to fill out the Patient Assessment Form. This form will be used to collect your physician's info as well as your personal health info. All information is securely stored and is not shared with anyone outside the Cannascribe network.
General Details
First Name *
As it appears on your Health Card or Passport
Middle Name
As it appears on your Health Card or Passport
Last Name *
As it appears on your Health Card or Passport
Health Card Number
Date of Birth *

Day Month Year
Date Date Picker Icon
Current Age *
Gender *

Male Female Other
If female, are you pregnant or nursing?

Yes No
Contact Information
Street Address *
Apt/Unit/PO Box
City *
Province / State *
Postal / Zip Code *
Phone Number *

Area Code Phone Number
Email *
example@example.com
Preferred Contact Method *

Phone Email
General Practitioner Information
Physician's Name

First Name Last Name
Date of Last Visit

Day Month Year
Date Date Picker Icon
Reason for Last Visit
Are you seeing a specialist?

Yes No
Specialist's Name

First Name Last Name
Date of Last Visit

Day Month Year
Date Date Picker Icon
Your Medical Condition & Symptoms
Primary Condition *
Check symptoms associated with your Primary Condition

Indicate level of symptom severity: Level 1 - Not Severe. Level 5 - Very Severe.

Pain *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Muscle Spasms *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Mobility *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Headache *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Seizures *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Involuntary Movements *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Nausea / Vomitting *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Low Energy *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Diarrhea *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Constipation *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Medication Side Effects *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Anxiety *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Depression *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Concentration / Focus *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Sleep Disturbance *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Visual Disturbance *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Weight Loss *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Other *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Other
Please describe symptom
Medical History

How much does your condition affect your daily routine? *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Comments

How much does your condition affect your ability to work? *

	1	2	3	4	5

1 is Not Severe, 5 is Very Severe

Comments
Current Medications
Please indicate dosage
Drug Allergies
What therapies have you tried?
Please check all that apply. Please rate the effectiveness on a scale of 1 to 3
(1 Not Effective, 2 Effective, 3 Very Effective)

Physiotherapy

	1	2	3

1 is Not Effective, 3 is Very Effective

Chiropractic

	1	2	3

1 is Not Effective, 3 is Very Effective

Naturopathic / Homeopathic

	1	2	3

1 is Not Effective, 3 is Very Effective

Counselling / Psychotherapy

	1	2	3

1 is Not Effective, 3 is Very Effective

Therapeutic Injections

	1	2	3

1 is Not Effective, 3 is Very Effective

Acupuncture

	1	2	3

1 is Not Effective, 3 is Very Effective

Current Prescription
Please indicate name of medication and dosage
Have you been diagnosed with any dependence on any drug, prescribed or otherwise? *

Yes No
Have you previously used cannabis for symptom relief? *

Yes No
Have you suffered from Psychotic Illness currently or in the past? *

Yes No
Has a close member suffered from Psychotic Illness? *

Yes No
Would you feel at risk using cannabis outside your current medical treatment? *

Yes No
Do you suffer from heart disease? *

Yes No
How much cannabis do you use per day? *
What is your preferred method of taking cannabis? *

Inhalation / Smoke Oral / Eat Topical / Cream None, I do not use cannabis currently
What are your treatment goals? *

Reduce Pain Improve Daily Function Improve Mood Improve Appetite Improve Sleep Involuntary Movements
Why is cannabis appropriate as a medical treatment for you? *

Medical Documents Release Forms.

Cannascribe will require your medical records. If your doctor is unable to assist you or if you cannot get access to your physician, medical records that support your diagnosed ailment will need to be collected in one of two ways; on your own from your doctors receptionist by requesting your medical history, or we can obtain them with a completed Release Form. The completed Release Form can be submitted by you or Cannascribe can submit it on your behalf. Please choice the best option below.
Consent to Disclose Personal Health Information. Select one of the options below *

Send me the Release Form and I will submit it to my physician Send me the Release Form to be filled in by me and then please submit on my behalf I do not have a physician currently or medical records to support my condition

Patient Release Form
I understand that this Release and Acknowledgment contains IMPORTANT information about medical cannabis that the assessing physician requires that I acknowledge and understand before he/she may issue a prescription and/or authorization for use of medical cannabis.

I further understand that the consulting physician will not necessarily be assuming care for me. He/She will, however, assess and evaluate the appropriateness of my request to use medical cannabis to assist in treating the conditions and associated symptoms that I believe; from my own personal experience, medical cannabis to be helpful in treating.

I accordingly confirm that the assessing physician will be my medical practitioner for the sole purpose of medical cannabis authorization and/or prescriptions.

I agree not to make any claim or commence any legal proceedings against the assessing physician, his/her practice, my family physician or any other involved physicians (such as specialists) in relation to:

1. my use of cannabis as a medicine; and

2. my Application or, prescription for possessing, obtaining and using medical cannabis.

I am well aware that physicians generally agree that medical cannabis;

• May distort perception (sights, sounds, touch, time);

• May impair memory and learning

• May impair coordination

• May impair thinking and problem-solving

• May increase heart rate and reduces blood

• May produce anxiety, fear, distrust or panic.
I accept *

Yes

I am well aware there is considerable debate and a great lack of consensus among physicians about;

• The appropriate medical use of cannabis;

• The appropriate dosage for medical cannabis;

• The risks of smoking medical cannabis as compared to vaporizing or ingesting medical cannabis;

• The risks of smoking whole plant medical cannabis as compared to extracting the medicinally active cannabinoids;

• The long-term health and psychological risks associated with the use of medical cannabis;

• The degree to which regular consumption of medical cannabis;

• May contribute to pulmonary infections and respiratory cancer;

• May damage the cells in the bronchial passages which protect the body against inhaled microorganisms and decrease the ability of the immune cells in the lungs to fight off fungi, bacteria, and tumour cells. For patients with already weakened immune systems, this means an increase n the possibility of dangerous pulmonary infections, including pneumonia;

• May weaken various natural immune mechanisms, including macrophages and T-cells.

• May correlate in some cases with mental illness, such as a bipolar disorder and schizophrenia
I accept *

Yes

I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products, I generally consume a medication of a precise known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way. I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from the strain of plant.

I further appreciate that there is significant uncertainty regarding the consistency of medical cannabis, which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis.

I am aware that ingesting a high dose of medical cannabis can cause nausea and disorientation.
I accept *

Yes

In seeking medical cannabis treatment I confirm I have consulted with a physician’s alternative and conventional treatment options for my condition.
I accept *

Yes

Despite all these medical concerns, debates and practical issues, I honestly believe that for the treatment of my condition(s) and symptom(s) the benefit of medicating with medical cannabis outweigh the risks.
I accept *

Yes

This is my decision and I also do not support any claims made by my family, friends or other interested parties against said clinic and physicians.
I accept *

Yes

I hereby release the assessing physician, his/her clinic, my family physician, and any other involved physicians from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to my use of medical cannabis.
I accept *

Yes

This release from liability is to be binding on heirs, executors and assigns. I also consent to the disclosure, sharing and use of my personal information and medical data by the assessing physician, Cannascribe and my licensed producer. The information may be used to contact, address and register the patient and for analysis and research to better help our members.
I accept *

Yes

I understand and acknowledge that while the assessing physician may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing physician will not serve as my primary care physician. As such, I agree to seek regular medical care from my primary care physician and that the assessing physician will only deal with assessing his/her support from my medical cannabis use. I also consent to the assessing physician notifying any specialists have seen my decision to use medical cannabis and I accept any consequences of such notification.
I accept *

Yes

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