Therapeutic Form

Your login name

First Name

Middle Name

Last Name

If you are filling this form in with the medical user please provide your name below

Helper Name

Date of Birth (e.g. dd-mm-yyyy)

House Number or Name

Street

Locality

City

County /State / Province / Region

Country

ZIP / Postal Code

Telephone (e.g. international dialing code, +44 161 298 0298)

Your Email Address

Your General Practitioner's or Doctor's Name

Your weight in Kg

Your height

Your Occupation

How many children do you have ?

These notes are prompts, please add anything else that you have experienced even if you feel it may not be relevant.

1. Previous Cannabis Use

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2. Presenting complaint (eg type of cancer, primary location, where it has spread to and any other conditions)
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2a. Current medicine used.

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3. Past medical History (operations, illnesses, allergies, accidents, childhood illnesses etc)

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4. Drug history (immunisations, painkillers, vaccinations, contraceptives, vitamins and supplements)

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5. Other complementary medical support (other therapies you have used or currently use)

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6. Family history (hereditary conditions, significant relationships, children)

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7. Social history (smoking, drugs, drinking, exercise, work, hobbies)

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8. General: do you feel tired, emotional, weak, easily catch illnesses that are going around, take a long time to recover from
illnesses, feel tired after meals, crave unusual foods?

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9. Cardiovascular system: have you ever experienced chest pain, fainting, palpitations, swelling of your ankles, varicose veins/piles, and cold extremities?
Have you ever been treated for a cardiovascular related condition?

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10. Respiratory system: do you regularly suffer with catarrh, earache, sore throat, and coughs?
Do you have any other respiratory conditions e.g. asthma?

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11. Gastrointestinal system: have you ever experienced problems with your digestion, your teeth, with constipation and/or
diarrhoea, abdominal pain, bloating, vomiting? How is your appetite? Are you happy with your weight?

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12. Urinary system: do you need to urinate often, is there urgency, poor stream or difficulty starting?
Do you experience loin pain? Do you suffer from recurring cystitis or kidney stones?

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13. Nervous system: do suffer from sleep disturbance, headaches, visual disturbances, hearing loss/ tinnitus, dizziness, vertigo,
fainting, fits, poor memory, weakness, tremor, pins and needles, cold extremities? Do you experience depression or other mood changes?

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14. Gynaecological system: what age did you start to menstruate, are you still menstruating or peri/post menopausal, do you suffer from PMS?

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15. Muscular skeletal system: do you suffer from joint pain or stiffness, joint swelling, lumps/bumps on joints, pain to you back or neck?
Have you ever suffered from whiplash or concussion? Do you have carpal tunnel syndrome?

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16. Skin: do you have acne, rashes, fungal infections, itching, herpes, extremely dry skin, hair loss?

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17. Allergies:

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Please attach any blood tests or details of other tests that you feel may be relevant.

Please click the "Browse Button" to Attach your PDF Files (max file size 8mb)

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