Patient questionnaire
Sign in to Google to save your progress. Learn more
Email *
Legal First and Surname *
Gender *
New Zealand Resident 
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
DO YOU SUFFER FROM ANY OF THE FOLLOWING SYMPTOMS?
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? *
Have you or anyone in your family ever had a Psychotic episode? *
Are you pregnant? *
Are you breast feeding? *
Do you have a history of addiction or substance abuse? *
Do you use cannabis on a regular basis? *
Has cannabis use ever made you paranoid or psychotic? *
Have you ever used cannabis before? *
Do you smoke cigarettes? *
Do you drink alcohol? *
If so, how many standard drinks do you consume per week? *
How did you hear about us? *
Are you ok with us sending a copy of our clinical letter to your GP? *
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. *
Please make sure you click the Green Submit button below!
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
This content is neither created nor endorsed by Google.