Cliquez ici pour la version française > Step 1 of 5 20% Name* First Last Email* Phone*What is your birth date?* Day Month Year Please note you must be 20 years or older to obtain a licence. What is your Skype ID or email you used to create your Skype account?* If you don't have an account please visit www.skype.com to register (phone or computer). For existing Skype users please add Skype username: Cannabis_Consulting Click Here for help finding your Skype IDCurrent Address* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Is the address above the same as your mailing address?*YesNoWhat is your mailing address?* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code How did you hear about us?*My friend got a licenceA hydroponics storeI found you on googleFacebookOtherWhat is the name of the store?* Chief problem(s) for which medical cannabis is being requested: List all your current medications including dosage List any medications you are allergic to: Do you use cocaine or other “street” drugs?*NoYesPlease list any street drugs do you currently use and how often you use them. Do any of your medications contain opiates? (Codeine, Morphine, etc.)*NoYesDo you currently use cannabis for relief?*NoYesPlease check all that apply. vapor edible topical smoke How often do you use cannabis?*EverydayEvery other day1-2 times per weekOnce per weekOtherHow often do you intake cannabis? Have you ever experienced an unpleasant/unwanted side effects of cannabis?*NoYesPlease describe your side effect.* Are you aware of the possible side effects that may occur from use of cannabis?*YesNoHave you ever been diagnosed with schizophrenia?*NoYesHave you ever been diagnosed as bipolar?*NoYesAre you on any psychiatric medications?*NoYesPlease list your medications and daily dosage.*Have you ever been diagnosed with any form of autism?*NoYes, I'm high functioningYes, aspergers syndromeYes, pervasive developmental disorderYes, autistic disorderHow would you rate your cannabis growing skills?*1- I don't know anything2 - I'm still learning3 - I'm okay4 - I'm pretty good5 - I'm an expert Do you currently hold a prescription for medical cannabis?*NoYesDo you have or have you ever had any of the following medical conditions: Asthma/Lung Disease Hepatitis Stroke Kidney Disease Thyroid Heart Disease Cancer ADD/ ADHD Substance Abuse Depression MS Schizophrenia Hyper Tension No, I have not had any of these Please check all that applyDo you currently use tobacco products?*NoYesDo you consume alcohol?*NoYes Which area do you feel pain the most?*I currently don't feel any painHeadArmsLegsBackNeckKneesElbowsOtherWhich area do you feel pain? Rate your pain level in the last 24 hours*1 - no pain2345 - a lot of painIn the past 24 hours how much has pain interfered with your general activity?*1 - no pain23 - medium pain45 - a lot of painIn the past 24 hours how much has pain interfered with your ability to concentrate?*1 - no pain23 - medium pain45 - a lot of painIn the past 24 hours how much has pain interfered with your appetite?*1 - no pain23 - medium pain45 - a lot of painIn the area where you have pain, do you have “pins and needles”, tingling or prickling sensations? Yes No Does the painful area change colour (perhaps mottled or red) when the pain is particularly bad? Yes No Does your pain make the affected skin abnormally sensitive to the touch? Yes No Does your pain come on suddenly and in bursts for no apparent reason when you are completely still? Yes No In the area where you have pain, does your skin feel unusually hot like burning pain? Yes No Gently rub the painful area with your index finger and then rub a non-painful area. How does the rubbing feel in the painful area? No difference Discomfort – pins and needles, tingling or burning in the painful area Gently press on the painful area with your fingertip then gently press in the same way to a non painful area. How does this feel in the painful area? No difference Discomfort – pins and needles, tingling or burning in the painful area HADS (Hospital Anxiety & Depression Scale) - Please read each statement below and choose the number which best describes how true the feeling is for you.I wake early and then sleep badly for the rest of the night.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI get very frightened or have panicked feelings for apparently no reason at all.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI feel miserable and sad.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI feel anxious when I go out of the house on my own.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI have lost interest in things.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI get palpitations, or sensations of “butterflies” in my stomach or chest.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI have a good appetite.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI feel scared or frightened.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyHave you ever thought about committing suicide?I've never thought about itI've thought about it in the past but not anymoreI currently think about itI've attempted suicideI still enjoy the things I used to.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI am restless and can't keep still.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI am more irritable than usual.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyI feel as if I have slowed down.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyWorrying thoughts constantly go through my mind.0 - No, not at all1 - No, not much2 - Yes, sometimes3 - Yes, definitelyPlease add any notes you feel are of importance Upload a clear photo of your ID (drivers licence, health card, or passport)* Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 256 MB, Max. files: 1. 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