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Initial Intake Questions
Welcome to our brief healthcare questionnaire
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* Indicates required question
Email
*
Your email
First and last name
*
Please enter the first and last name of the patient.
Your answer
Best email address(es) for updates
Your answer
Best telephone number to reach you
Your answer
Best address for receiving mail deliveries
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Exact diagnosis - include comorbidities (diabetes, high blood pressure, etc.)
Your answer
ICD10 Code (if known)
Your answer
Date of Diagnosis
MM
/
DD
/
YYYY
All medications and supplements currently taking (add more lines as needed)?
Your answer
Any previous and current experience with cannabis?
brand and types of products, if known
Your answer
What is your objective using cannabis?
select as many as apply
*
Pain relief
Anti-cancer therapy
Pharmaceutical replacement
Sleep
Mental health
Manage side effects of chemotherapy
Seizure control
Other:
Required
Where medicine will be sourced, if known (dispensary name and location)?
Your answer
What is your zip (postal) code?
*
Your answer
Have you ever sought support for a mental health issue?
Yes
No
Other:
Clear selection
How did you learn about our services?
Referral by a friend
Referral by healthcare provider
Web search
Social media
Saw in a documentary
Other:
Clear selection
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