PATIENT DETAILS
First Name
Last Name
Date of Birth
Mobile Phone Number
Email
BACKGROUND
I have been seeing the patient as usual practitioner for at least the past 3 months. —Please choose an option—YesNo
I have access to enough past medical history to support this referral —Please choose an option—YesNo
Other available conventional treatment options have been used previously. —Please choose an option—YesNo
Previous treatment outcomes: —Please choose an option—Suboptimal resultsAdverse-efects
Qualifying medical conditions Alzheimer's DiseaseAnorexiaAnxietyADHDASDCachexiaCancer symptom managementCancer-related painChemotherapy-induced nausea / vomitingChronic non-cancer painCrohn's diseaseDementiaDepressionEndometriosisEpilepsyInflammatory bowel disease (IBD)InsomniaIrritable bowel syndrome (IBS)Mood disorderMultiple sclerosis (MS)Neuropathic painOsteoarthritisPalliative careParkinson's diseasePTSDSeizure managementSleep disorderSpasticitySpasticity-associated painOther
Please specify other
Warning signs NilSuicide attempt/sSuicidal ideas / intentsDrug dependence / Substance abuseSevere COPD / Asthma
Contraindications (Please do not refer a patient if a contraindications is ticked or if contraindications are ticked)
Current or history of: NilSchizophreniaAcute psychosisUnstable severe bipolarMyocardial infarction Current: NilUnstable anginaAngina pectorisPregnancy / BreastfeedingPlans for imminent pregnancy
Symptoms management strategies so far Non-opioid AnalgesicsNSAIDsOpioid analgesicsSurgical intervention/sUS-Guided injection/sCT-Guided injections/sNerve pain agentsAnti-depressantsAnxiolyticsSleeping agentsPsychotherapy / CBTOther
Specialist/s involved NilOrthopaedic / Spinal surgeonPain specialistNeurologistOncologistPsychiatristGastroenterologistSleep PhysicianGynaecologistOther
Allied Health Providers involved NilPhysiotherapistChiropractorExercise PhysiologistOccupational TherapistPodiatristDieticianPsychologistOther
Patient currently / has been previously using cannabis. —Please choose an option—YesNo
PREVIOUS CANNABIS USE
From - to
Amount
Frequency
REFERRING DOCTOR
Doctor Name
Practice Name
Practice Phone Number
Practice Fax Number
Practice Email
Referral date
Please upload a copy of the patient's Health Summary
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