Zoto - Questionnaire

Medical Cannabis...
Patient Medical Questionnaire

Please complete this form to the best of your knowledge, this will help our team process your application so we may provide you with a consultation with of of our medical professionals.

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First Name *

Last Name *

Email Address *

Password *

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Email Verification

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Date of Birth *

Gender *

GP / Specialist Details

The Zoto clinic will need to contact your GP or specialist’s clinic to request your medical records. This process can sometimes cause a delay in patients getting their prescriptions. We always advice patients to contact their GP or specialist’s clinic notifying them of their intention to seek medical cannabis medications. You cannot receive a prescription without your previous medical records.

GP/Specialist Contact Details *

Next of Kin Information *

Medical History

Please describe in detail the medical condition(s)/problem(s) that you have received a diagnosis for. This condition must of been diagnosed by a GP, Specialists or medical professional.

This will help us to establish how we can help you. At Zoto we specialise in management of pain and related symptoms traditionally be treated in a pain clinic.

Diagnosed Medical Conditions *

Do you have a history of heart problems including palpitations, heart attack (MI), stroke, angina, chest pain, shortness of breath, arrhythmias (funny heart beats), pacemaker, or taking any heart medications? *

Yes

Are you currently being treated for cancer or undergoing any cancer treatments? *

Yes

Are you currently taking Immunosuppressants or Immunotherapy medication? *

Yes

Do you have any history of Liver Disease including hepatitis, elevated liver enzyme function blood tests, fatty liver cirrhosis? *

Yes

Are you currently pregnant? *

Yes

Date of Last Menstrual Period (if applicable)

Psychiatric history - Have you ever been referred to a psychiatrist health service? *

Yes

Have You Ever Been Diagnosed With? *

Mania (bipolar disorder)

Schizophrenia

Depression

PTSD

Anxiety Disorders including Generalized Anxiety disorder, OCD or other?

Personality Disorder?

Are you currently or previously suicidal?

None

Family History - Does anyone in your family sufer from any of the following conditions? *

Psychosis

Schizophrenia

Schizoafective disorder

Anxiety

Depression

Bipolar/Manic Depression/ Mania

None

What is their relation to you? (ie. parent/sibling/cousin/uncle/aunt/child):

Drug and Alcohol History - Do you have any personal history of drug abuse or dependency such as: heroin, cocaine, LSD, marijuana, ecstasy, GHB, legal highs such as spice, prescription drug abuse (such as opioids, prescription painkillers or benzodiazepines)? *

Yes

Do you have a history of alcohol abuse or dependency? *

Yes

Have you ever been under the care of drug and alcohol services? *

Yes

How many units of Alcohol do you drink per week? *

Do you use cannabis to reduce or eliminate the use of any medications that have been prescribed for your medical condition? *

Yes

Cannabis History - If you do use cannabis currently, how ofen do you use cannabis? *

Everyday

Every other day

1-2 times per week

Never

How have you used cannabis? *

Smoking (joints)

Vaporizing

Ingestion

Topical

Never

If you use a vaporizer, which vaporizer do you use?

What strains have you found most helpful? (Check all that apply)

Indica

Sativa

Hybrid

What names of strains have you used (if known?) ie ‘OG Shark, pink kush, etc’: *

If known, which strains/names have you found most useful for which symptom? (Ie OG shark for headache or Indica for night pain etc) *

How much cannabis do you currently use per day? Ie number of ounces, grams or joints per day. *

How many times per day do you use cannabis? *

Have you had any serious reaction to cannabis? *

If you have tried cannabis for your symptoms in the past but stopped, why did you stop cannabis? *

Please list - CURRENT PRESCRIPTIONS AND OVER THE COUNTER SUPPLEMENTS (including details of any over the counter CBD oils/products if applicable) *

Please list any medications you have tried in the past *

First Name *

Last Name *

Email Address *

Mobile Number *

Street Address *

Town/City *

Postcode *

Country *

Patient Declaration

I confirm that the information provided in this medical questionnaire is correct and complete to the best of my knowledge. I understand that failure to provide true and correct information could result in my prescribed medical cannabis being withdrawn by the prescribing specialist.

Patient Signature *

All questions and information in this questionnaire are strictly confidential and will be kept secure.

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