Patient Questionnaire

Thank you for your interest in Santé Cannabis

Before booking your first appointment we require all of the following:

  1. Referral from a physician, specialist, or nurse practitioner [form found here]
  2. This questionnaire
  3. Medical summary (relevant notes, consultations, imaging reports, etc.) as well as a 3-5 year prescription history from your pharmacy

(1) and (3) can be requested and submitted by fax, mail, email, and/or submitted in person.

Once all the necessary documents have been received, we will review and evaluate whether you are a candidate for medical cannabis. This review can take around 12 weeks and if eligible for medical cannabis, you will be contacted at a later date to set an appointment.


    Were you referred to Santé Cannabis by a treating physician or nurse practitioner?


    Social situation

    What is your employment status?

    Please indicate if you receive government assistance

    Reason for visit and Medical History

    Please indicate any of the following treatments that you have tried

    PhysiotherapyMassage therapyPsychotherapy or counsellingAcupunctureOther

    Please indicate the presence or history of the following conditions

    Unstable Heart DiseaseLiver DiseaseCOPD, asthma or other respiratory conditionSchizophrenia or psychosis, or family history of psychosisBipolar disorder or borderline personality disorderAttention deficit disorder, obsessive compulsive disorderHistory of sexual or physical abuseCurrently pregnant or breastfeeding or planning to become pregnantNone of the above

    Please describe your mental health history, have you experienced depression, anxiety or other mental health symptoms?


    Please describe how your medical condition(s) is currently affecting the following aspects of your life:

    Recreational Drug Use

    Do you drink alcohol?

    Do you currently smoke cigarettes?

    Have you ever consumed other recreational drugs, other than cannabis?


    Cannabis use

    Have you ever consumed cannabis for recreational purposes?

    Do you currently use cannabis to treat your medical condition and symptoms?


    How often do you consume cannabis?

    How do you consume cannabis?

    Smoked, in a joint, pipe or bongVaporizedEaten, in a food product, tea or oilOther

    Have you ever held an MMPR, MMAR or ACMPR authorization or been a member of a dispensary or compassion club?


    Information Sharing

    Do you consent to sharing the information you have provided in this questionnaire with your primary care or referring physician?