Medicinal Cannabis
 Patient Intake & Consent Form

PATIENT'S DETAILS

title: <<Patient Demographics:Title>> surname: <<Patient Demographics:Surname>>  given name(s):  <<Patient Demographics:First Name>>  <<Patient Demographics:Middle Name>>
date of birth: <<Patient Demographics:DOB>>
MEDICINAL CANNABIS QUESTIONNAIRE
What is the primary diagnosis or medical condition you are looking to treat with medicinal cannabis?

	  chronic pain		  cancer pain		 epilepsy		 neurological disorder	

	  chemotherapy induced nausea and vomiting	

 Other conditions  	

	

Have you previously or are you currently self-medicating with cannabis?	yes	no	

 What other treatments have you trialled for this condition?	

	

 What other medications have you previously used, list the side effects if any, and reason for stopping?	

	

Do you currently experience, or have a history of the following?

	 Psychosis		 unstable cardio-respiratory disease	
				
	 Bipolar Disorder		 pregnant or breastfeeding	
				
	 mood disorder or severe anxiety		 drug dependence or substance abuse	

PATIENT DECLARATION & CONSENT

I understand that the long-term side effects of medicinal cannabis are unknown.	yes	no	

I understand that medicinal cannabis is not registered in Australia by the Therapeutic Goods Admin- istration of the Australian Department of Health and Ageing. Therefore, arrangements to access/import these medicines need to be made through a Special Access Scheme or Authorised Prescriber scheme.	yes	no	

I understand that that the Australian government’s Therapeutic Goods Administration (TGA) doesn’t guarantee quality, safety and efficacy of medicinal cannabis.	yes	no	

I understand that the prescribing doctors may report my treatment outcomes to the state government.	yes	no	

I understand that the cost of medicinal cannabis is solely my responsibility.	yes	no	

I understand that it is an offence to drive in Australia with any level of tetrahydrocannabinol (THC) in my blood or saliva and if I drive, I am breaking the law.
A legally issued prescription is not protecting against these laws.	yes	no	

I understand the risks and complications associated with medicinal cannabis treatment and I agree to follow my doctor’s recommendation with regards to dosing and report any adverse effects of medicinal cannabis, including changes in the levels of sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhoea, drowsiness, dizziness, disorientation, agitation, balance problems, changes in memory, paranoid delusions, or hallucinations.	yes	no	

I understand that there is a possibility of unknown risks and late side effects.	yes	no	

I understand that medicinal cannabis might interact with my other medications and
 doses may need to be adjusted according.	yes	no	

I agree to keeping a log of my doses and changes in symptoms due to medicinal cannabis.	yes	no	

I agree to regular follow up consultations in the surgery or over the phone and indicated by my doctor.	yes	no	

I agree that I will not use any other forms of cannabis other than what prescribed by my doctor, this includes any elicit forms of cannabis (marijuana).	yes	no	

I agree to notify my prescribing doctor of any changes in my other medications.	yes	no	

I agree to share my clinical outcomes for research purposes.	yes	no	

		I declare that all answers in this Medicinal Cannabis Patient Intake & Consent Form are true and 			correct to the best of my knowledge and belief.

         signature of patient or guardian................................................................date:  <<Miscellaneous:Date (short)>>