Cliquez ici pour la version française > Step 1 of 5 20% Name* First Last Email* Phone*What is your occupation?*What is your birth date?* DD MM YYYY Please note you must be 25 years or older to obtain a licence.Here's why we don't offer licences for people under 25 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?*A hydroponics storeI found you on googleMy friend got a licenceFacebookOtherWhat is the name of the store?* Chief problem(s) for which medical cannabis is being requested:List all your current medications including dosageList 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 What plant count do you require for your medicinal needs?*5 grams (25 Indoor plants, or 10 Outdoor plants)10 grams (49 Indoor plants, or 19 Outdoor plants)20 grams (98 Indoor plants, or 38 Outdoor plants)30 grams (146 Indoor plants, or 57 Outdoor plants)40 grams (195 plants indoors or 76 Outdoor plants)50 grams (244 Indoor plants, or 95 Outdoor plants)60 grams (292 Indoor plants, or 114 Outdoor plants)70 grams (341 Indoor plants, or 133 Outdoor plants)80 grams (390 Indoor plants, or 152 Outdoor plants)95 grams (463 Indoor plants, or 181 Outdoor plants)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 expertDo you grow more than one strain? List all strains grown below: Do you currently hold a prescription for medical cannabis?*NoYesHow many grams do you currently have a persciption for?Do 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 applyList the name, last date seen and type of health care provider (doctor, chiropractor, therapist, psychologist, counselor, specialist or other (please specify) that you consult for your medical condition(s):Have you had any prior surgeries?Do you currently use tobacco products?*NoYesHow often do you use tobacco per week?Do you consume alcohol?*NoYesHow oftern do you drink alcohol per week?*Please add any notes you feel are of importance Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches). Have you had pain other than these everyday kinds of pain today?NoYesWhich area do you feel pain the most?*HeadArmsLegsBackNeckKneesElbowsPlease rate your pain by checking the one number that best describes your pain at its worst in the past 24 hours.*1 - no pain2345 - a lot of painPlease rate your pain by checking the one number that best describes your pain on average.*1 - no pain2345 - a lot of painPlease rate your pain by checking the one number that best describes how much pain you have right now.*1 - no pain2345 - a lot of painIn the past 24 hours, how much relief have pain treatments or medications provided? Please check the one percentage that most shows how much relief you have received*0% - no pain25%50% - medium pain75%100% - 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 mood?*1 - no pain23 - medium pain45 - a lot of painIn the past 24 hours how much has pain interfered with your walking ability?*1 - no pain23 - medium pain45 - a lot of painIn the past 24 hours how much has pain interfered with your work?*1 - no pain23 - medium pain45 - a lot of painIn the past 24 hours how much has pain interfered with your relationships with other people?*1 - no pain23 - medium pain45 - a lot of painIn the past 24 hours how much has pain interfered with your sleep?*1 - no pain23 - medium pain45 - a lot of painIn the past 24 hours how much has pain interfered with your enjoyment of life?*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, definitelyUpload a clear photo of your ID (drivers licence, health card, or passport)* Drop files here or Accepted file types: jpg, jpeg, gif, png, pdf. Please review our terms and conditions* I agree to the Terms and Conditions Can you confirm all your answers are truthful without omission?* Yes, I confirm © 2020 LICENCE TO GROW | ALL RIGHTS RESERVED | TERMS | PRIVACY POLICY