Patient Intake Form

Patient Information

  • - select your title -
  • Mr.
  • Mis.

If female? are you pregnant or nursing?

Preferred Contact Method*

General Practitioner Information

Date of last visit?

Are you seeing a specialist?

Specialist's Name

Your Medical Condition

Check symptoms associated with your Primary Condition

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

Pain*

Muscle Spasms*

Mobility*

Headache*

Seizures*

Involuntary Movements*

Nausea / Vomitting*

Low Energy*

Diarrhea*

Constipation*

Medication Side Effects*

Anxiety*

Medical History

How much does your condition affect your daily routine?*

  • - select a option -
  • 1
  • 2
  • 3
  • 4
  • 5

Level 1 - Not Severe, Level 5 - Very Severe

Comments

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

  • - select a option -
  • 1
  • 2
  • 3
  • 4
  • 5

Level 1 - Not Severe, Level 5 - Very Severe

Comments

Current Medications / Prescription

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 Not Effective, 2 Effective, 3 Very Effective

Chiropractic

1 Not Effective, 2 Effective, 3 Very Effective

Naturopathic / Homeopathic

1 Not Effective, 2 Effective, 3 Very Effective

Counselling / Psychotherapy

1 Not Effective, 2 Effective, 3 Very Effective

Therapeutic Injections

1 Not Effective, 2 Effective, 3 Very Effective

Acupuncture

1 Not Effective, 2 Effective, 3 Very Effective

Have you been diagnosed with any dependence on any drug, prescribed or otherwise?*

Have you previously used cannabis for symptom relief?*

Have you suffered from Psychotic illness currently or in the past?*

Has a close member suffered from Psychotic Illness?*

Would you feel as risk using cannabis outside your current medical treatment?*

Do you suffer from heart disease?*

How much cannabis do you use per day?*

What is your preferred method of taking cannabis?*

What are your treatment goals?*

What are your treatment goals?*

TURTLE ISLAND NATURALS

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