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Medical Cannabis Questionnaire

This Medical Questionnaire is designed to ensure that Cannabidiol (CBD) may be effective in treating your specific condition or symptoms. In just a few moments you will find out if you qualify for a medical CBD prescription as regulated by the Department of Health and the Therapeutic Goods Administration in Australia. Please complete the requested sections and follow the prompts:

If you are filling this out on behalf of a minor please answer from the perspective of the patient

Are you age over 18? *

Could you be pregnant or are you currently breast feeding? *

Do you suffer from any of the following medical conditions?
Do you have any of the following medical documents?
Medications

What medications are you currently taking?

Please identify current medications, daily dose / frequency:

Please identify current medications, daily dose / frequency:

Please identify current medications, daily dose / frequency:

Please identify current medications, daily dose / frequency:

Please identify current medications, daily dose / frequency:

Have you used CBD before? *

Did you have any side effects or problems? *

if yes, what were they?

Allergies

Do you have any allergies to medication, food or other substances? *

if yes, to what?

Any others?