Patient questionnaire

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Email *

Legal First and Surname *

Gender *

Female

Male

Prefer not to say

Other:

New Zealand Resident *

yes

Full Address - Suburb/City/Postcode *

Full Date of Birth Day/Month/Year *

Contact number *

Doctor *

GP Clinic *

NHI (if known)

DO YOU SUFFER FROM ANY OF THE FOLLOWING CONDITIONS? PLEASE SELECT

Heart Disease

Lung Disease

Diabetes

Phaeochromocytoma

Thyroid Disease

High Blood Pressure

DO YOU SUFFER FROM ANY OF THE FOLLOWING SYMPTOMS?

Headaches

Palpitations

Sweating

WHAT IS THE MAIN REASON YOU’RE WANTING MEDICINAL CANNABIS? for eg pain/anxiety/sleep? *

PLEASE LIST ANY MEDICAL CONDITIONS YOU HAVE? For eg Diabetes, Epilepsy, Anxiety etc

PLEASE LIST ANY MEDICATIONS YOU’RE TAKING? (If so, please list them)

ARE YOU ALLERGIC TO ANY MEDICATIONS? (If so, please list them) *

Have you or anyone in your family ever been diagnosed with Schizophrenia? *

If you have personally been diagnosed with Schizophrenia, you must email us a letter from your doctor confirming this diagnosis. This evidence is required to proceed with your appointment.

Yes

Have you or anyone in your family ever had a Psychotic episode? *

If you have personally had a Psychotic episode, you must email us a letter from your doctor confirming this diagnosis. This evidence is required to proceed with your appointment.

Yes

Are you pregnant? *

Yes

N/A

Are you breast feeding? *

Yes

N/A

Do you have a history of addiction or substance abuse? *

Yes

Do you use cannabis on a regular basis? *

Yes

Has cannabis use ever made you paranoid or psychotic? *

Yes

N/A

Have you ever used cannabis before? *

Yes

Do you smoke cigarettes? *

Yes

Do you drink alcohol? *

Yes

If so, how many standard drinks do you consume per week? *

Less than 2 std drinks per week

Between 2 and 14 standard drinks per week

Between 14 and 21 standard drinks per week

More than 21 standard drinks per week

I dont drink alcohol

How did you hear about us? *

Google

Facebook

Word of Mouth

Walked past clinic

New World

G.P or Specialist

other social media platforms

Are you ok with us sending a copy of our clinical letter to your GP? *

Yes

Are you being prescribed medicinal cannabis by any other medical practitioner? If so, please provide the name of the doctor or clinic.

Please note that if you cancel within 24 hours of your appointment or do not answer your phone for your consult you will NOT be eligible for a refund. *

Yes, I accept Green Doctors' cancellation policy.

Required

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