NEW PATIENT INTAKE FORM

General Information

Title *

MrMs

Patient first name *

Patient surname *

Date of birth *

Email Address *

Mobile Number *

Address *

Street address *

City *

State *

Postcode *

Gender *

MaleFemalePrefer not to say

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship to you *

Medicare Number *

IRN (Number Next to your name on Medicard) *

Expiry Date *Please fill out Year then Month Example (2027-06)

Are you of Aboriginal or Torres Strait Islander Origin? *

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNeither Aboriginal or Torres Strait Islander

Health Information

Have you had a chronic illness for more than 3 months? TGA guidelines state that you must have a chronic condition for more than 3 months *

YesNo

If your above answer is no, you are not eligible for this treatment

List the Chronic Illness or Illnesses *

Doctor *

GP Address *

Street address *

City *

State *

Postcode *

Please list any medications you are currently taking

Medications

Please list any allergies

Have you ever been prescribed psychotic or opiate based medicines ? *

YesNo

If yes please inform us what medication and duration ?

Are you pregnant or breastfeeding? *

YesNoNot Applicable

Have you ever been diagnosed with Substance Dependence? *

YesNo

Do you have thoughts of suicide/hurting yourself or others? *

YesNo

Has a close family member suffered from a mental illness? *

YesNo

Do you smoke? *

YesNoI used to smoke

How do these reasons affect your quality of living? *

RarelySlightlyModeratelySeverely

Do you use or do you have history of using Cannabis? *

YesNo

Have you had any negative side effects after consuming cannabis? *

YesNoNot Applicable

If yes, what were the side effects?

Why do you think alternative medicines, like cannabis, can help your conditions?

Consent

I have completed the above patient intake form truthfully and to the best of my abilities and consent to this information being given to our staff for consult booking purposes

I have carefully read the terms and conditions and privacy policy

*

I understand that the doctor has the right to refuse treatment at their discresion *

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