Start Your Assessment All fields marked * are required. Enter your full legal name as you would like it recorded. EmailThis field is for validation purposes and should be left unchanged.Personal InformationFirst Name(Required)Last NameEmail(Required) We will use this email to contact you about your intake and any follow-up.Phone number (optional)Optional — provide a phone number if you are comfortable being contacted by phone or SMS. Conditions & SymptomsSelect your condition(s) or symptom area(s)(Required)ADHDALSAlzheimer’s Disease / Cognitive DeclineAnxietyArthritisAutoimmune DisorderAutism Spectrum DisorderBipolar DisorderCancer / Cancer-Related SymptomsChronic FatigueChronic PainCrohn’s Disease / Inflammatory Bowel DiseaseDepressionEndometriosisEpilepsy / Seizure DisorderFibromyalgiaGlaucomaHIV / AIDSInflammation / Chronic Inflammatory ConditionsLower Back PainMenstrual Pain / PMSMigraines / Chronic HeadachesMultiple SclerosisNausea / VomitingNeuropathic Pain / Nerve DamageNeurodegenerative DiseaseObsessive-Compulsive Disorder (OCD)Parkinson’s DiseasePediatric Case (under legal age)Phantom Limb PainPsoriasis / Skin ConditionPost-Traumatic Stress Disorder (PTSD)Restless Leg SyndromeSchizophrenia / Psychotic DisorderSleep Disorder / InsomniaSpinal Cord InjuryStress-Related SymptomsTourette SyndromeTraumatic Brain InjuryOtherSelect all that apply. Use 'Other' to specify conditions not listed.OtherDiagnosis status for selected condition(s)(Required) Yes No Unsure Have you been formally diagnosed by a healthcare provider? Diagnosing provider (optional)Name and/or clinic of the provider who made the diagnosis (if applicable). Approximate date of diagnosis (optional) MM slash DD slash YYYY Provide the month/day/year if known. Symptoms & SeverityWhat symptoms are you seeking support for?PainSleep disturbanceAnxiety or stressDepression or low moodMuscle spasms or tremorsNausea or appetite issuesFatigueInflammationNeurological symptomsOtherSelect all that apply. Use 'Other' to specify additional symptoms.Other(Required)Symptom severity (average)(Required) 0 1 2 3 4 5 6 7 8 9 10 Overall symptom severity (0 none — 10 severe) How often do symptoms occur?(Required) Daily Several times per week Weekly Intermittent Symptoms interfere with Sleep Work / School Mobility Daily activities Relationships Focus / cognition Select areas of life affected by your symptoms. Treatment HistoryPrevious treatment types tried Prescription medications Over-the-counter medications Therapy / counselling Physiotherapy Alternative treatments Surgical or procedural interventions Other Select treatments you have tried. Use 'Other' to add additional treatments.OtherHow effective were previous treatments? Effective Partially effective Not effective Stopped due to side effects Please list any significant side effects experiencedInclude medication or treatment name and the side effect if known. Safety & Medical ScreeningSafety & medical screening — applicable items Pregnant or planning pregnancy Breastfeeding History of psychosis or schizophrenia History of bipolar disorder (mania) Active suicidal thoughts Significant heart condition Severe liver condition History of adverse reaction to cannabis Other Select any that apply. These items help ensure safe clinical review. OtherCurrent medication use (select all that apply) Opioids Benzodiazepines Antidepressants Antipsychotics Mood stabilizers Blood thinners Sleep medications Stimulants Other Select medications you are currently taking. 'Other' can be used to list additional medications. OtherLifestyle considerations I drive regularly I operate machinery I work in a safety-sensitive role Select any that apply to your daily activities or work. Cannabis ExperiencePrior cannabis experience (optional) Never used Previously used Currently using occasionally Currently using regularly If applicable, adverse effects experienced with cannabis Anxiety or panic Paranoia Dizziness Sedation No adverse effects Other OtherConsent & SubmissionConsent to assessment Consent to assessment - By checking this box I confirm that I am providing accurate information to the best of my knowledge, that I understand this is a pre-screening intake only, that no treatment is guaranteed or implied, and that I consent to review of my information by a licensed healthcare practitioner. Privacy acknowledgment Privacy acknowledgment - I consent to the collection and use of my personal health information for assessment, communication, and care coordination in accordance with applicable privacy laws. Submit Your Intake Next step: Once submitted, your information will be reviewed. If appropriate, you may be contacted for a free clinical consultation. FacebookThis field is for validation purposes and should be left unchanged.Your email address(Required)
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