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Formulaire d’admission du patient
Formulaire d’admission du patient
Translator
2019-03-11T01:43:12-04:00
Merci de répondre aux questions le plus sérieusement possible.
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Nom Complet
*
Prénom
Nom
Email
*
Numéro de téléphone
*
What is your occupation?
*
Date de naissance
*
Jour
Mois
Année
Vous devez être âgés de 20 ans ou plus afin d’obtenir votre licence
Identifiant Skype ou adresse e-mail utilisée pour la création de votre compte Skype?
*
Si vous n’avez pas de compte Skype, merci de vous en créer un sur le site
www.skype.com
(mobile ou ordinateur). Pour les utilisateurs de skype, merci d’ajouter Cannabis_Consulting Cliquez ici pour obtenir de l’aide si vous ne trouvez pas votre identifiant Skype
Adresse actuelle
*
Rue et numéro
Complément d’adresse
Ville
Province
Alberta
Colombie-Britannique
Manitoba
Nouveau-Brunswick
Terre-Neuve-et-Labrador
Territoires du Nord-Ouest
Nouvelle-Écosse
Nunavut
Ontario
Île du Prince-Édouard
Québec
Saskatchewan
Yukon
Code postal
L’adresse ci-dessus est-elle la même que votre adresse d’expédition ?
*
Oui
Non
What is your mailing address?
*
Rue et numéro
Complément d’adresse
Ville
Province
Alberta
Colombie-Britannique
Manitoba
Nouveau-Brunswick
Terre-Neuve-et-Labrador
Territoires du Nord-Ouest
Nouvelle-Écosse
Nunavut
Ontario
Île du Prince-Édouard
Québec
Saskatchewan
Yukon
Code postal
Comment avez-vous entendu parler de nous
*
Magasins hydropiques
Google
Un ami a obtenu sa licenceUn ami a obtenu sa licence
Facebook
Other
Quel est le nom du magasin ?
*
Chief problem(s) for which medical cannabis is being requested:
List all your current medications including dosage
List any medications you are allergic to:
Do you use cocaine or other “street” drugs?
*
Non
Yes
Please list any street drugs do you currently use and how often you use them.
Do any of your medications contain opiates? (Codeine, Morphine, etc.)
*
Non
Yes
Do you currently use cannabis for relief?
*
Non
Yes
Please check all that apply.
vapor
edible
topical
smoke
How much cannabis are you hoping to obtain? (grams per day ) :
*
5 grams
10 grams
20 grams
30 grams
40 grams
50 grams
other
Please list desired number of grams per day.
How often do you use cannabis?
*
Everyday
Every other day
1-2 times per week
Once per week
Other
How often do you intake cannabis?
Have you ever experienced an unpleasant /unwanted side effect of marijuana? (
*
Non
Yes
Please describe your side effect.
Are you aware of the possible side effects that may occur from use of marijuana?
*
Yes
Non
Do you currently hold a prescription for medical cannabis?
*
Non
Yes
How many grams do you currently have a persciption for?
Do you have or have you ever had any of the following medical conditions:
Asthma/Lung Disease
Hepatitis
Stroke
Kidney Disease
Thyroid
Heart Disease
Cancer
ADD/ ADHD
Substance Abuse
Depression
MS
Schizophrenia
Hyper Tension
No, I have not had any of these
Please check all that apply
List the name, last date seen and type of health care provider (doctor, chiropractor, therapist, psychologist, counselor, specialist or other (please specify) that you consult for your medical condition(s):
Have you had any prior surgeries?
Do you currently use tobacco products?
*
Non
Yes
How often do you use tobacco per week?
Do you consume alcohol?
*
Non
Yes
How oftern do you drink alcohol per week?
*
Please add any notes you feel are of importance
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches). Have you had pain other than these everyday kinds of pain today?
Non
Yes
Which area do you feel pain the most?
*
Head
Arms
Legs
Back
Neck
Knees
Elbows
Please rate your pain by checking the one number that best describes your pain at its worst in the past 24 hours.
*
1 - no pain
2
3
4
5 - a lot of pain
Please rate your pain by checking the one number that best describes your pain on average.
*
1 - no pain
2
3
4
5 - a lot of pain
Please rate your pain by checking the one number that best describes how much pain you have right now.
*
1 - no pain
2
3
4
5 - a lot of pain
In the past 24 hours, how much relief have pain treatments or medications provided? Please check the one percentage that most shows how much relief you have received
*
0% - no pain
25%
50% - medium pain
75%
100% - a lot of pain
In the past 24 hours how much has pain interfered with your general activity?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your mood?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your walking ability?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your work?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your relationships with other people?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your sleep?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your enjoyment of life?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your ability to concentrate?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the past 24 hours how much has pain interfered with your appetite?
*
1 - no pain
2
3 - medium pain
4
5 - a lot of pain
In the area where you have pain, do you have “pins and needles”, tingling or prickling sensations?
Oui
Non
Does the painful area change colour (perhaps mottled or red) when the pain is particularly bad?
Oui
Non
Does your pain make the affected skin abnormally sensitive to the touch?
Oui
Non
Does your pain come on suddenly and in bursts for no apparent reason when you are completely still?
Oui
Non
In the area where you have pain, does your skin feel unusually hot like burning pain?
Oui
Non
Gently rub the painful area with your index finger and then rub a non-painful area. How does the rubbing feel in the painful area?
No difference
Discomfort – pins and needles, tingling or burning in the painful area
Gently press on the painful area with your fingertip then gently press in the same way to a non painful area. How does this feel in the painful area?
No difference
Discomfort – pins and needles, tingling or burning in the painful area
HADS (Hospital Anxiety & Depression Scale) - Please read each statement below and choose the number which best describes how true the feeling is for you.
I wake early and then sleep badly for the rest of the night.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I get very frightened or have panicked feelings for apparently no reason at all.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel miserable and sad.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel anxious when I go out of the house on my own.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I have lost interest in things.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I get palpitations, or sensations of “butterflies” in my stomach or chest.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I have a good appetite.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel scared or frightened.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel life is not worth living.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I still enjoy the things I used to.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I am restless and can't keep still.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I am more irritable than usual.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
I feel as if I have slowed down.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
Worrying thoughts constantly go through my mind.
0 - No, not at all
1 - No, not much
2 - Yes, sometimes
3 - Yes, definitely
Upload a clear photo of your ID (drivers licence, health card, or passport)
*
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