canna

🌿 CANNA Care | Client Assessment

0 of 33 questions answered 0%

Client Assessment Form

Please complete the following clinical assessment with accurate information. Your data is protected under strict medical confidentiality and will be used to personalise your care safely.

General Client Information

1. Full name:

2. Identification number:

3. Date of birth:

4. Phone:

5. Email address:

6. City of residence:

7. Occupation:

Cannabis Use History

9. Have you used cannabis before?

Yes No Maybe

10. How long have you been using cannabis?

Less than 6 months 6 months to 1 year 1 to 5 years More than 5 years

11. How often do you use cannabis?

Daily Several times a week Once a week Occasionally First time

12. Which products do you usually use?

Flower Oils Edibles Vaporizers Extracts Other

13. What is your main reason for using cannabis?

Chronic pain Stress Anxiety Insomnia Relaxation Recreational Other

14. Have you noticed any benefits from cannabis use?

Yes No

15. If yes, which ones?:

Symptoms & Wellbeing Assessment

16. Do you have any of the following conditions?

Chronic pain Insomnia Anxiety Stress Migraines Muscle spasms Inflammation None of the above

17. Rate your average pain level from 0 to 10:

Select a level (0 = No pain, 10 = Worst pain)

18. Do you have trouble sleeping?

Never Occasionally Frequently Every day

19. How many hours do you sleep on average?:

20. Do you experience episodes of anxiety or stress?

Never Occasionally Frequently

Medical History

21. Do you have any diagnosed medical condition?

Yes No

22. If yes, please specify:

23. Are you currently taking any medication?

Yes No

24. Which medications do you take?:

25. Do you have a history of:

Cardiovascular disease Epilepsy Psychiatric disorders Hypertension None

26. Have you ever had adverse reactions to cannabis?

Yes No

Safety Assessment

27. Are you pregnant or breastfeeding?

Yes No Maybe

28. Do you regularly drive or operate heavy machinery?

Yes No

29. Have you received medical guidance about cannabis use?

Yes No

30. What THC percentage do you usually use?:

31. How many grams do you use per month?:

32. Do you prefer indica, sativa or hybrid varieties?

Indica Sativa Hybrid

33. Have you had episodes of anxiety, paranoia or tachycardia related to cannabis use?:

Clinical Assessment Summary

canna.

ES EN