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Patient Details

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Questionnaire

What is the primary diagnosis or medical condition for which you seek treatment with medicinal cannabis?

Have you ever self-medicated or are you currently self-medicating with cannabis?

Yes No

What other treatments have you tried for this condition?

What medications have you previously used? List any side effects and your reason for stopping.

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

Anything else you would like to mention?

Are you pregnant, breastfeeding, or considering pregnancy?

Yes No

Patient Declaration

I understand that the long-term side-effects of medicinal cannabis are unknown.

Yes No

I understand that medicinal cannabis is an unregistered medicine in Australia.

Yes No

I understand that the quality, safety, and efficacy of medicinal cannabis have not been assessed by the Australian government’s Therapeutic Goods Administration.

Yes No

I understand that the prescribing doctor will report my treatment outcomes to the government.

Yes No

I understand that the cost of medicinal cannabis is solely my responsibility.

Yes No

I understand that I must not drive or operate heavy machinery whilst taking medicinal cannabis containing THC. If I drive under these circumstances, I am breaking the law. I understand that a legally issued prescription does not provide a defence to such an offence.

Yes No

I understand the risks and complications associated with medicinal cannabis treatment. I agree to follow my doctor’s recommendation regarding dosing. I agree to report any adverse effects I experience from taking medicinal cannabis, including but not limited 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 side effects.

Yes No

I understand that medicinal cannabis might interact with my other medications, and doses may need to be adjusted accordingly.

Yes No

I agree to keep a log of my doses and changes in symptoms due to medicinal cannabis.

Yes No

I agree to attend regular follow-up consultations in the clinic or over the phone as directed by my doctor.

Yes No

I agree that I will not use any form of cannabis other than that prescribed by my doctor, including any illicit form of cannabis (marijuana).

Yes No

I agree to share my clinical outcomes for research purposes.

Yes No

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

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Patient Details

Questionnaire

Patient Declaration