Are you under the care of a doctor (GP / consultant)? *
Did you discuss medical cannabis with your personal doctor? *
Do you have diagnostic evidence of your condition? *
Required
Do you have a history of heart disease or respiratory disease? *
Are you under the care of a psychiatrist? *
Do you have a personal or family history of schizophrenia or bipolar disorder? *
List the names of the medications you are using or have used in the past to relieve your symptoms *
Your answer
Were the medications effective to relieve symptoms? *
What side effects did the medication give you? *
Your answer
Did you ever have any trouble with the police? Do you have pending court cases? Are you on probation ? *
Did you ever attend Detox Centre (for substance misuse) in the past? *
What is your current occupation? *
Your answer
Have you ever used cannabis or CBD before? *
Required
Who referred you to The Pain Clinic?
Your answer
By selecting "Agree" below, you declare that you take full responsibility of your use of this medicine. If you smoke, sell, share, drive under the influence or abuse the medicine in any way, you could be liable to criminal charges. *