Pre-consultation: Medical Cannabis

First name *

Last name *

Email *

Phone *

Date of birth *

What condition would you like to treat with medical cannabis? *

Chronic pain

Neuropathic pain

Epilepsy

Multiple sclerosis spasticity

Chemotherapy-induced nausea

Fibromyalgia

PTSD

Anxiety

Insomnia

Inflammatory bowel disease

Tourette's syndrome

Appetite stimulation

Other

How long have you had this condition? *

Less than 3 months

3-6 months

6-12 months

1-2 years

2-5 years

More than 5 years

Current severity: *

Mild

Moderate

Severe

Debilitating

Impact on daily life (work, relationships, self-care): *

No impact

Minor impact

Significant impact

Unable to work/care for self

List all medications you've tried for this condition (name, dose, duration, response): *

Medical cannabis is typically considered after conventional treatments have been tried and found inadequate. Please list all treatments you've tried for this condition.

How many conventional medications have you tried for this condition? *

1

2

3

4

More than 4

Why did conventional treatments fail? (select all that apply) *

Didn't work

Side effects intolerable

Allergic reaction

Partially effective but not enough relief

Too sedating

Other

Have you tried non-medication treatments? (select all that apply) *

Physiotherapy

CBT (Cognitive Behavioural Therapy)

Acupuncture

TENS (Transcutaneous electrical nerve stimulation)

Exercise programmes

Pain management programme

Psychological therapy

None

What medications are you currently taking for this condition? *

Are you currently being treated by a specialist for this condition? *

Yes

No

Have you used cannabis before (recreationally or medicinally)? *

Yes - currently using

Yes - in the past

No - never used

Have you had any adverse reactions to cannabis? *

Yes

No

Have you ever experienced psychosis (hearing voices, seeing things, paranoid thoughts)? *

Yes

No

Family history of psychosis or schizophrenia? *

First-degree relative with psychosis increases risk. THC can trigger psychosis in susceptible individuals.

Yes - first-degree relative (parent/sibling)

Yes - second-degree relative (grandparent/aunt/uncle)

No

History of cannabis-related anxiety or panic? *

Yes

No

History of substance addiction (alcohol, opioids, other drugs)? *

Yes - currently active

Yes - in recovery/abstinent

No

Bipolar disorder? *

Yes

No

Depression? *

No

Mild

Moderate

Severe

Have you had thoughts of harming yourself or suicide in the past month? *

SAFETY QUESTION - Your safety is paramount. We will discuss this with you.

Yes - with a plan

Yes - but no plan

Thought about it but wouldn't do it

No

Personality disorder diagnosis? *

Yes

No

Age: *

Brain development continues until age 25. Under 25, cannabis use carries additional risk.

Pregnant or planning pregnancy? *

CONTRAINDICATION: Cannabis use in pregnancy is not recommended due to potential effects on fetal development.

Yes - currently pregnant

Yes - planning pregnancy

No

Are you breastfeeding? *

CONTRAINDICATION: THC passes into breast milk and may affect infant development.

Yes

No

Heart disease or arrhythmia? *

Yes

No

Uncontrolled high blood pressure (>140/90)? *

Yes

No

Don't know

Recent heart attack or stroke (within 6 months)? *

CONTRAINDICATION: Recent cardiac events are a contraindication to cannabis.

Yes

No

Do you smoke tobacco? *

Yes

No

Respiratory conditions (asthma, COPD, chronic bronchitis)? *

Yes

No

Preferred administration route: *

Vaporised flower

Oil/tincture (sublingual)

Capsules

No preference

Want specialist advice

Do you drive a car or operate other vehicles? *

Yes

No

Does your occupation involve safety-critical tasks? (operating machinery, healthcare, transport, emergency services, military) *

Yes

No

Full list of all current medications (including supplements and herbal remedies): *

Are you taking opioid painkillers? *

Yes

No

Are you taking benzodiazepines (e.g. diazepam, lorazepam)? *

Cannabis + benzodiazepines = combined sedation risk.

Yes

No

Are you taking antipsychotic medications? *

Yes

No

Are you taking blood thinners (warfarin, apixaban, rivaroxaban)? *

CBD can interact with warfarin metabolism - close monitoring required.

Yes

No

What are you hoping for? (select all that apply) *

Start medical cannabis treatment

Switch from illegal to legal prescribed cannabis

Adjust current prescription strength/product

Reduce or stop other medications

Get a second opinion

General advice about medical cannabis

Other

Preferred product type if starting treatment: *

CBD-dominant

Balanced THC:CBD

THC-dominant

No preference

Want recommendation

Anything else we should know to help you?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Condition & Treatment History

What condition would you like to treat with medical cannabis? -

How long have you had this condition? -

Current severity: -

Impact on daily life (work, relationships, self-care): -

Previous Treatment Attempts

List all medications you've tried for this condition (name, dose, duration, response): -

How many conventional medications have you tried for this condition? -

Why did conventional treatments fail? (select all that apply) -

Have you tried non-medication treatments? (select all that apply) -

What medications are you currently taking for this condition? -

Are you currently being treated by a specialist for this condition? -

Cannabis Experience

Have you used cannabis before (recreationally or medicinally)? -

Have you had any adverse reactions to cannabis? -

Safety Assessment

Have you ever experienced psychosis (hearing voices, seeing things, paranoid thoughts)? -

Family history of psychosis or schizophrenia? -

History of cannabis-related anxiety or panic? -

History of substance addiction (alcohol, opioids, other drugs)? -

Bipolar disorder? -

Depression? -

Have you had thoughts of harming yourself or suicide in the past month? -

Personality disorder diagnosis? -

Age: -

Pregnant or planning pregnancy? -

Are you breastfeeding? -

Cardiovascular Health

Heart disease or arrhythmia? -

Uncontrolled high blood pressure (>140/90)? -

Recent heart attack or stroke (within 6 months)? -

Respiratory Health

Do you smoke tobacco? -

Respiratory conditions (asthma, COPD, chronic bronchitis)? -

Preferred administration route: -

Driving & Occupation

Do you drive a car or operate other vehicles? -

Does your occupation involve safety-critical tasks? (operating machinery, healthcare, transport, emergency services, military) -

Medication Interactions

Full list of all current medications (including supplements and herbal remedies): -

Are you taking opioid painkillers? -

Are you taking benzodiazepines (e.g. diazepam, lorazepam)? -

Are you taking antipsychotic medications? -

Are you taking blood thinners (warfarin, apixaban, rivaroxaban)? -

Your Goals & Preferences

What are you hoping for? (select all that apply) -

Preferred product type if starting treatment: -

Anything else we should know to help you? -

Upload supporting documents

If you have specialist letters confirming treatment failure or blood test results, please upload them here.

Click to upload files

Anything else for your doctor?