Upgraded Eligibility Form

Personal Information

Date of Birth

Your Health Conditions

Please select all that apply.

Prescription Check

I have been prescribed a medication or tried therapy for pain, sleep or mental health
(This can be a current or past prescription.) I have never been prescribed a medication.

Address & Gender

Gender: Male Female Other

Medical History (1/5)

Please describe in detail the medical condition(s) you have been diagnosed with.

Do you have a history of heart problems (palpitations, attack, stroke, angina, chest pain, breathlessness)?

Yes No

Are you currently being treated for cancer or undergoing any cancer treatments?

Yes No

Are you currently taking Immunosuppressants or Immunotherapy medication?

Yes No

Do you have any history of Liver Disease?

Yes No

Medical History (2/5)

Psychiatric history - Have you ever been referred to a psychiatrist health service?

Yes No

Have You Ever Been Diagnosed With?

Mania (bipolar disorder) Schizophrenia Depression PTSD Anxiety Disorders Personality disorder Currently or previously suicidal None

Family History: Does anyone in your family suffer from any of the following?

Psychosis Schizophrenia Schizoaffective disorder Anxiety Depression Bipolar/Manic Depression/Mania None

Medical History (3/5)

Do you have any personal history of drug abuse or dependency?

Yes No

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?

Medical History (4/5)

Do you use cannabis to reduce or eliminate the use of any medications that have been prescribed for your medical condition?

Yes No

If you do use cannabis currently, how often do you use cannabis?

Every Day Every other day 1–2 times per week Never

How have you used cannabis? (Select all that apply)

Smoking (joints) Vaping Ingestion Topical Never

How much cannabis do you currently use per day?

Have you had any serious reaction to cannabis?

Medical History (5/5)

Please list current prescriptions and over-the-counter supplements (incl. any CBD oils/products):

Consent & Submit

Preferred Contact Methods:

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I confirm that the information provided is true and accurate.