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Auraceuticals Patient Assessment Form

Welcome to The Auraceuticals powered by our Online Medical Cannabis Prescription Services portal. You are about to fill out the Patient Assessment Form. This form will be used to collect your physician's info as well as your personal health info. All information is securely stored and is not shared with anyone outside The Auraceuticals network.

Step 1 of 6

Name*
First Middle Last
Health Card Number*
Please Upload 2 Forms of Government Identification*
Drop files here or
Please upload ANY medical documents or previous medical cannabis prescriptions you may have.*
Drop files here or
Date of Birth*
Current Contact Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Preferred Date & Time For Health Practitioner to Call
Date MM/DD/YEAR
Time: Example 10 AM
Preferred Contact Method*
- Phone
- Email
- Text Message
General Practitioner/Physician Name & Information*
First Last
Date and Reason for Last Visit
Are you seeing a specialist ?*
Specialist's Name
Prefix First Last
Date of Last Visit

Patient Health Questionnaire (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems ?
Little interest or pleasure in doing things*
Feeling down, depressed, or hopeless*
Trouble falling or staying asleep, or sleeping too much*
Feeling tired or having little energy*
Poor appetite or overeating*
Feeling bad about yourself - or that you are a failure or have let yourself or your family down*
Trouble concentrating on things, such as reading the newspaper or watching television*
Moving or speaking so slowly that other people could have noticed. Or the opposite - being so figety or restless that you have been moving around a lot more than usual*
Thoughts that you would be better off dead, or of hurting yourself*
GAD - 7
Over the last 2 weeks, on how many days have you been bothered by any of the following problems
Feeling nervous, anxious or on edge*
Not being able to stop or control worrying*
Worrying too much about different things*
Trouble relaxing*
Being so restless it is hard to sit still*
Becoming easily annoyed or irritable*
Feeling afraid as if something awful might happen*

Hospital Anxiety and Depression Score (HADS)
This questionnaire helps your physician to know how you are feeling. Read every sentence. Choose the answer that best describes how you have been feeling during the LAST WEEK. You do not have to think too much to answer. In this questionnaire, spontaneous answers are most important.
A - I feel tense or "wound up"
D- I still enjoy the things I used to enjoy:
A - I get a sort of frightened feeling as if something awful is about to happen:
D- I can laugh and see the funny side of things
A - Worrying thoughts go through my mind:
D- I feel cheerful:
A - I can sit at ease and feel relaxed
D - I feel as if I am slowed down:
A - I get sort of frightened feeling like 'butterflies' In the stomach*
D - I have lost interest in my appearance:*
A - I feel restless as I have to be on the move:*
D - I look forward with enjoyment to things:*
A - I got sudden feeling of panic*
D - I can enjoy a good book or radio or TV program:*

Medical Cannabis Consultancy Agreement
In consideration of my receiving orientation and referral services and assessment for medical cannabis, I, the Client, agree as follows:
Consent
I agree to the privacy policy & medical cannabis consultancy agreement.
- 1. Purpose/Safety/Information
- a. The purpose of this contract is to maintain a safe, controlled treatment plan.
- b. The information I am providing to Auraceuticals and/or the associated physician(s) is confidential & medical and identifying information and is for the purposes of Data collection.
- c. The information is intended to be a consolidated personal medical record as conveyed by me, of my symptomatic, medical & personal histories to the clinical consultant for the purposes of Data collection.
- d. The clinical consultant, who will provide medical cannabis orientation to me, does not intend to communicate to me or my personal representative a diagnosis identifying a disease or disorder as the cause of my symptoms in which it could be implied or inferred, in any way, or, by any party, that I or
- e. The information collected may be utilized for review by a licensed health care practitioner or other licensed professional as deemed appropriate by me or Auraceuticals within the territory of Canada.
- f. This document does not imply or otherwise guarantee in any way any medical outcome relating to controlled acts such as the prescribing of medicine or Auraceuticals within the territory of Canada.
- g. This document and any information collected during the consultancy process is retrieved via written & verbal consent from myself.
- h. Data collected within the consultancy process becomes & remains the property of Auraceuticals for all intents and purposes within the scope of the respective acts regarding the use, dissemination and storage of Personal Health Information (PHI) in accordance with the Canadian Personal Information Protection and Electronic Documents Act, the Alberta Personal Information Protection Act, the British Columbia Personal Information Protection Act , the New Brunswick Personal Health Information Privacy and Access Act, the Newfoundland and Labrador Personal Health Information Act, the Nova Scotia Personal Information International Disclosure Act, Ontario Personal Health Information Protection Act, the Quebec Act Respecting the Protection of Personal Information in the Private Sector.
- i. That the assessment, diagnosis and possible treatment of my medical condition(s) with medical cannabis; that any inaccurate or false information given by me may adversely impact the healthcare practitioner’s ability to diagnose my condition and recommend
- 2. Last Resort/Compliance
- a. I am asking for medical cannabis because other treatments and medications I have used have not provided relief of my symptoms and illness.
- b. It is unlikely that any medication will completely take away all of my symptoms, but for humane reasons, I understand that medical cannabis may be authorized for so long as my condition continues if I follow the terms of this contract.
- c. If I fail to follow the terms of this contract, this will result in the discontinuation of medical cannabis authorizations and possible discharge from Auraceuticals.
- d. I will only be discussing the legal methods of obtaining medical cannabis in Canada.
- 3. Not Primary Care
- a. I understand and acknowledge that while the assessing healthcare practitioner may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing healthcare practitioner will not serve as a point of primary care.
- b. As such I agree to seek regular medical care from my primary care physician and that the assessing healthcare practitioner will only deal with assessing his support for my medical cannabis use.
- c. I also understand that the possible complications of treatment with medical marihuana (marihuana therapy) may include, but are not limited to the following: CHEMICAL DEPENDENCE (ADDICTION), DIFFICULTY WITH URINATION, DROWSINESS, NAUSEA, ITCHING, SLOWED RESPIRATION, REDUCED SEXUAL FUNCTION and IMPAIRED MOTOR FUNCTION. If I take more medication than what is prescribed, a dangerous situation could result, such as coma, organ damage, or even death. I understand that if I run out of my medication too soon, or if my medication is stopped suddenly, I could experience uncomfortable or dangerous withdrawal symptoms. If I experience any serious side effects after ingesting cannabis, I will report to the nearest hospital emergency department.
- 4. For Women
- a. If I become pregnant, there are known and unknown risks to the unborn child, which include addiction and the possibility of the baby experiencing withdrawal at birth.
- b. I am obligated to let my healthcare practitioners know if I am pregnant, and they will help me find ways of controlling my symptoms without cannabis.
- 5. Exclusivity/No Medicine Replacement
- a. I will inform Auraceuticals about my medical cannabis use and all other related medications and side effects.
- b. During the period of the medical cannabis authorization obtained through Auraceuticals, I will NOT contact any physicians or health care practitioners who do not work for Auraceuticals regarding medical cannabis. If it is found that I received a prescription for cannabis medications from a source other than Auraceuticals, I will be discharged from Auraceuticals and any prescriptions and authorizations for cannabis mediation will be discontinued.
- c. I agree to take the cannabis medication exactly as instructed by Auraceuticals healthcare practitioners.
- d. I am NOT allowed to change dosage amounts or alter the time schedule of taking the medication without talking to Auraceuticals healthcare practitioner.
- e. I agree that Auraceuticals will NOT replace any lost, stolen, or inaccessible cannabis medications or prescriptions for any reasoner.
- 6. Legal Duties/Renewal
- a. I understand that it is my responsibility to stay informed regarding provincial, federal and local laws and regulations regarding the possession and use of medical cannabis.
- b. It is also my responsibility to ensure that a renewal appointment is made one month prior to the expiry of the current authorization.
- c. During my renewal appointment, the nurse practitioner will reevaluate me for a possible continuance of medical cannabis.
- 7. Benefits Test
- a. I understand that the benefits of my medical cannabis consultation will be evaluated regularly using the following criteria of i. Symptom relief; ii. Increase in general function; iii. Increase in life activities; iv. Reduction in pain or discomfort intensity levels; v. The absence of unacceptable side effects; vi. Ability to work and maintain employment
- 8. Screening
- a. I agree to periodic urine screens for other medications and drugs if Auraceuticals healthcare practitioners deem it appropriate.
- 9. NO Illegal Drugs, Resale, or Hoarding
- a. I agree to the following: i. I am NOT currently abusing illicit or prescription drugs and; ii. I am not undergoing treatment for substance dependence or abuse and; iii. I have never been involved in the illegal sale, possession, or transport of drugs and; iv. I will store all medical marihuana in a safe and secure manner away from children and; v. I will not hoard, sell or give away my medicine.
- 10. Privacy Policy
- a. We at Auraceuticals respect and value your privacy.
- b. We will collect, store or share information for the following purposes: i. To carry out the normal operations of our business, perform a service for you, to administer or coordinate your care or medication and to act upon your instructions. These uses may include but are not limited to discussing our services or answering your queries, processing or administering your connection with or communicating with your health care practitioners or other Licensed Producers and maintaining proper records and this will serve as your consent and direction to your physician(s) and Licensed Producer (“LP”) or any substitute LP which we select to share information, medical use reports and accounting with us, including without limitation the Medical Document, as requested. ii. to comply with legal, regulatory or insurance requirements, to comply with the terms of purchase and sale of all or substantially all of our business wherein the new entity, owner or operator will assume the responsibilities and rights we have in respect of this information, to create and/or provide data in a discrete manner and to serve you or to analyze and improve our services, and in all cases, employees are kept up to date with regard to the privacy and security practices of THE PANDAY GROUP.
- 11. Release
- a. I hereby release the assessing healthcare practitioner, his/her clinic, my family physician, and any other involved healthcare practitioners, clinical consultants, patient educators and Auraceuticals administrative staff from any and all actions, claims, causes of actions, complaints and demands for damages, loss, or injury whatsoever arising, including by family, friends and representatives, whether directly or indirectly.
- 12. Understanding of Agreement Terms
- a. This form has been fully explained to me, I have read it or have had it read to me, and I understand and agree to the terms of this contract.
- b. I certify that the information in this questionnaire is accurate and complete.
- c. If any part of this contract as outlined above is broken, I understand that it will result in my immediate discharge from Auraceuticals and discontinuation of all medical cannabis authorizations.
- 13. Safety
- a. Health Canada, the assessing healthcare practitioner and Auraceuticals staff have advised me that:
- b. Using cannabis is prohibited while driving or performing hazardous tasks such as operating heavy machinery and;
- c. That people in safety-oriented occupations or supervising children should also be vigilant to avoid medicating inappropriately, based on their responsibilities and;
- d. Depending on dosage and administration, impairment can last over 24 hours following the last usage.
- 14. Fee/Cancellation
- a. Auraceuticals is a medical patient referral service that charges a fee for services.
- b. To cancel an appointment, you must speak directly with one of the medical patient coordinators pr clinical consultants. Cancellations by email or phone message will not be accepted.
By initializing and / or signing this document, you affirm that all of the information in this Medical Cannabis Agreement is true and you agree to all of the ASSESSMENT, MEDICAL HISTORY, AGREEMENTS, ACKNOWLEDGEMENTS, and terms hereof.

Did you know?

Women are dominating the medical marijuana industry. According to Forbes, women make up 36% of the leaders in the cannabis industry, 63% of which are executive positions, including the CEO. That is in stark contrast to the rest of the business world where women only occupy 25% of top-level positions and only 5% of CEO spots.

Countless celebrities endorse and support the use of medical marijuana, including Snoop Dogg, Lady Gaga, Morgan Freeman, Miley Cyrus, Danny DeVito and many others. Even Whoopi Goldberg is in on the action, releasing her own line of female-focused topicals called Whoopi & Maya.

Medical Marijuana has been around for thousands of years. The first recorded use of cannabis for healing purposes was in 2737 BC. However, it wasn’t until years later that cannabis finally got its taxonomic identification from Carl Linnaeus.

Recent studies have shown that marijuana can actually facilitate the growth of new brain cells through a process called neurogenesis. Researchers have found this new cell growth happens primarily in the hippocampus, which is responsible for memory and understanding emotion. This would explain why marijuana has been successful in the treatment of depression, anxiety and other mood disorders.

Canada is a trend setter. The government has announced legislation that will legalize marijuana in Canada by October 17, 2018. When this comes into effect, Canada will be the second nation in the world (after Uruguay) to legalize marijuana.

A bag of marijuana was the first thing ever sold on the Internet over 40 years ago. Students from Stanford University arranged a deal between students from the Massachusetts Institute of Technology. The deal happened in 1971 and would go down in history as the first thing ever traded online (take that, Amazon).

Market analysts predict that the United States medical marijuana industry will be valued at almost 20 billion by the year 2024. In 2015, Statistics Canada estimated that Canada’s cannabis industry was already valued at over $6 billion and would grow exponentially after weed became legalized.

Auraceuticals Patient Assessment Form

Step 1 of 6

Preferred Date & Time For Health Practitioner to Call

What therapies have you tried?

Patient Health Questionnaire (PHQ-9)

GAD - 7

Brief Pain Inventory & Medical Cannabis Consultancy Agreement

Select one number that indicates how, in the past 24 hours, pain has interfered with your;

Hospital Anxiety and Depression Score (HADS)

Medical Cannabis Consultancy Agreement

1. Purpose/Safety/Information

2. Last Resort/Compliance

3. Not Primary Care

4. For Women

5. Exclusivity/No Medicine Replacement

6. Legal Duties/Renewal

7. Benefits Test

8. Screening

9. NO Illegal Drugs, Resale, or Hoarding

10. Privacy Policy

11. Release

12. Understanding of Agreement Terms

13. Safety

14. Fee/Cancellation

Did you know?