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Eligibility Check

Complete the eligibility check to see if you qualify for medical cannabis. It’s quick, easy, and confidential.

The questionnaire should take 5 to 10 minutes to complete and is essential for our team to assess your suitability for this treatment.

START

Contact Details

Please ensure all required fields are filled in correctly.

First Name*

Last Name*

Email Address*

Contact Number*

Date of Birth*

Gender*

Password*

Please make sure your password is a minimum 12 characters.

Confirm Password*

The passwords you have entered don't match.

Shipping Address

Please ensure all required fields are filled in correctly.

Address Line 1*

Address Line 2

City*

State*

Postal Code*

Country*

Are you a Business?

Type of Business

Business Name

Business Address Line 1

Business Address Line 2

Business City

Business State

Business Postal Code

Business Country

Medical Conditions

Please tick all that apply

Please ensure all required fields are filled in correctly.

ADHD

Agoraphobia

Anxiety

Appetite Disorders

Arthritis

Autistic Spectrum Disorder

Back and Neck Pain

Bipolar

Bladder Pain

Cancer Pain and Nausea

Chrohn's Disease or Colitis Pain

Chronic and Long Term Pain

Chronic Fatigue Syndrome (CFS)

Cluster Headaches

Complex Regional Pain Syndrome

Depression

Dermatology

DVT

Ehlers-Danlos Syndrome (EDS)

Epilepsy

Endometriosis

Female Gynaecological Pain

Fibromyaalgia

Irritable Bowel Syndrome (IBS)

Migraine

Multiple Sclerosis Pain and Muscle Spasm

Nerve Pain

OCD

Osteoporosis

Pakinson's Disease

Personality Disorder

Phantom Limb Pain

Post Traumatic Stress Disorder (PTSD)

Sciatica

Scoliosis

Sleep Disorders

Spondylolisthesis

The Menopause

Thalasemia Major Blood Disorder

Tinnitus

Tourette Syndrome

Trigeminal Neuralgia

Other Medical Conditions

Prescribed Medicines & Treatments

Please tick all that apply

Please ensure all required fields are filled in correctly.

Alprazolam

Alfentanil

Amitriptyline

Atomoxetine

Azathioprine

Buprenorphine

Bupropion

Citalopram

Clonazepam

Codeine

Codeine Phosphate

Co-Codamol (30/500)

Dexamfetamine

Diazepam

Diclofenac

Dihydrocodeine

Fentanyl

Fluoxetine

Fluoxetine (Prozac)

Gabapentin

Guanfacine

Infliximab

Lisdexamfetamine

Lithium

Lorazepam

Melatonin

Menthylphenidate

Meptazinol

Methadone

Methotrexate

Mirtazapine

Modafinil

Morphine

Naproxen

Nefopam

Nortripyline

Omepresol

Omezrapol

Oxycodone

Paroxetine

Pentacozine

Pethidine

Prednisolone

Propranolol

Remifentanil

Sertraline

Sodium Valproate

Suvorexant

Tapentadol

Temazepam

Tramadol

Trazodone

Triazolam

Venlafaxine

Zolpidem

Zopiclone

Other Prescribed Medicines / Treatments

Medical History (Part One)

Please ensure all required fields are filled in correctly.

Do you have a history of heart problems?*

Including palpitations, heart attack (MI), stroke, angina, chest pain, shortness of breath, arrhythmias (funny heart beats), pacemaker, or taking any heart medications

True
False

Are you currently being treated for cancer or undergoing any cancer treatments?* Yes
No

Are you currently taking Immunosuppressants or Immunotherapy medication?* True
False

Do you have any history of Liver Disease including hepatitis, elevated liver enzyme function blood tests, fatty liver cirrhosis?* True
False

Psychiatric history - Have you ever been referred to a psychiatrist health service?* Yes
No

Are you currently or previously suicidal?* Yes
No

Have You Ever Been Diagnosed With?*

Schizophrenia

Depression

Anxiety Disorders including Generalized Anxiety disorder, OCD or other?

Mania (bipolar disorder)

Personality Disorder

PTSD

None

Does anyone in your direct family suffer from any of the following conditions?*

(i.e. parent/sibling/cousin/uncle/aunt/child)

Psychosis

Schizophrenia

Schizoaffective Disorder

Anxiety

Depression

Bipolar/Manic Depression/Mania

None

Medical History (Part Two)

Please ensure all required fields are filled in correctly.

Do you have a history of alcohol abuse or dependency?* Yes
No

Have you ever been under the care of drug and alcohol services?* Yes
No

How many units of Alcohol do you drink per week?*

Do you use cannabis to reduce or eliminate the use of any medications that have been prescribed for your medical condition?* Yes
No

Cannabis History - If you do use cannabis currently, how often do you use cannabis?* Everyday
Every other day
1-2 times per week
Never

How have you used cannabis?*

Smoking (Joints)

Vaporizing

Ingestion

Topical

Never

How much cannabis do you currently use per day? (in Grams)*

Have you had any serious reaction to cannabis?* Yes
No

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