Patient Medical HistoryStep 1 of 333%Personal DetailsHiddenName(Required) First Name Last Name HiddenName(Required) First Name Last Name HiddenEmail(Required) Email Address Confirm Email HiddenPhone(Required)Please enter your mobile number without any spaces or country codesHiddenDate of Birth(Required) DD slash MM slash YYYY Address(Required) Street Address Address Line 2 City County Post Code Gender(Required) Male Female OtherMedical History Please describe in detail the medical condition(s)/problem(s) that you have received a diagnosis for. This condition must of been diagnosed by a GP, Specialists or medical professional.This will help us to establish how we can help you. At Integro Clinics we specialise in management of pain and related symptoms traditionally be treated in a pain clinic.Please declare your diagnosed condition(Required)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?(Required) Yes NoAre you currently being treated for cancer or undergoing any cancer treatments?(Required) Yes NoAre you currently taking Immunosuppressants or Immunotherapy medication?(Required) Yes NoDo you have any history of Liver Disease including hepatitis, elevated liver enzyme function blood tests, fatty liver cirrhosis?(Required) Yes NoAre you currently pregnant? Yes NoDate of Last Menstrual Period (Optional) MM slash DD slash YYYY Psychiatric history - Have you ever been referred to a psychiatrist health service?(Required) Yes NoHave You Ever Been Diagnosed With?(Required) Mania (bipolar disorder) Schizophrenia Depression PTSD Anxiety Disorders including Generalized Anxiety disorder, OCD or other? Personality Disorder? Are you currently or previously suicidal? NoFamily History - Does anyone in your family suffer from any of the following conditions and if so, what is their relation to you? (ie. parent/sibling/cousin/uncle/aunt/child): Psychosis Schizophrenia Schizoaffective disorder Anxiety Depression Bipolar/Manic Depression/ Mania NoDrug and Alcohol History - Do you have any personal history of drug abuse or dependency such as: heroin, cocaine, LSD, marijuana, ecstasy, GHB, legal highs such as spice, prescription drug abuse (such as opioids, prescription painkillers or benzodiazepines)?(Required) Yes NoDo you have a history of alcohol abuse or dependency?(Required) Yes NoHave you ever been under the care of drug and alcohol services?(Required) Yes NoHow 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?(Required) Yes NoCannabis History - If you do use cannabis currently, how often do you use cannabis?(Required) Everyday Every other day 1-2 times per week NeverHow have you used cannabis?(Required) Smoking (joints) Vaporizing Ingestion Topical NeverHow much cannabis do you currently use per day? Ie number of ounces, grams or joints per day.Have you had any serious reaction to cannabis?Please list - CURRENT PRESCRIPTIONS AND OVER THE COUNTER SUPPLEMENTS (including details of any over the counter CBD oils/products if applicable)Consent FormConsent(Required)I understand that the purpose of my consulting Big Narstie Medical & Partners is to have my medical condition assessed by appropriate specialists to see whether or not it is appropriate to recommend the use of cannabis based medical products (CBMP’s). I understand that the a fee will need to be paid for an overall assessment and not specifically for the prescription or recommendation of cannabis based medical products (CBMP’s). I understand that CBMP’s might not be recommended by Big Narstie Medical & Partners in my case. See the following link for further details on fees: https://bignarstiemedical.com/Integro_Standard_Fee_ Structure.pdf I understand that Big Narstie Medical & Partners is bound by national guidelines to recommend conventional investigations or treatments appropriate for my condition, where appropriate, before considering the prescription of medical cannabis preparations. I understand that if Big Narstie Medical & Partners does recommend that it is appropriate to prescribe CBMP’s for me, it will pass on the recommended prescription to its pharmacy team form for me, if that is what I wish. I will be responsible for the cost of those medications. I understand that Cannabis based medical products (CBMP’s) are different from most prescribed medicines. They are not licensed medical products, and do not have a marketing authorisation. They have not been subjected to the same rigorous safety, quality and efficacy standards that are in place for licensed medications. I understand that, at the present time, there is less medical experience generally with their use than with licensed medications. The producers of such CBMP’s are not subject to the same responsibilities as those who have marketing authorisations for authorised medical products. I understand that it is my duty to tell Big Narstie Medical & Partners about my medical condition and general health completely and truthfully. Failure to do so may result in reduced safety for myself, and Integro Medical Clinics Ltd may decline to carry on treating me. I understand that I must tell Big Narstie Medical & Partners if I am pregnant, or intend to become pregnant, or am liable to become pregnant, or alternatively to father a child while using cannabis-based products, or soon after. I am aware that use of cannabis-based products may affect my sexual health, and seriously affect the health of any children conceived or gestated (carried) or breast-fed, when CBMP’s are used. I understand that I have read and understood the leaflet: https://bignarstiemedical.com/Integro_Patient_Guide_2023.pdf “Cannabis based medical products”. I understand that CBMP’s may have adverse and unwanted medical side effects. More information is given on form“Cannabis based medical products”. I understand that these side effects may include dizziness, sedation, impaired judgement and soon, especially when commencing treatment or changing doses or preparations. This may seriously harm my ability to carry out many activities safely. Such activities include driving, operating machinery, cooking and using knives, caring for children, making important and professional decisions. Serious harm may occur as a result of carrying out such activities while adversely affected by using CBMP’s. I understand that care must be taken if combining the use of CBMP’s with other prescription medications, over the counter medications, herbal and illegal medications, and others. More information is given “Cannabis based medical products”. I understand that alcohol (ethanol) may interact with CBMP’s, and increase side effects such as dizziness , sedation, impaired judgement and so on. Document “Cannabis based medical products” contains more information about this. It is advisable not to take alcohol at all when using CBMP’s. I understand that if I do drive whilst using CBMP’s, I do so under my own responsibility. I should inform my motor insurers and DVLA, and carry a copy of my CBMP prescription with me in case I am stopped by the police. I understand that Big Narstie Medical & Partners may approach my general medical practitioner (GP) to request information about my over-all medical condition, the opinions of specialists and others I have consulted about my current medical problem, my physical and psychological history, and seek results of tests and investigations related to my current medical problem and health in general. I understand that my case will be considered and discussed by different members of Big Narstie Medical & Partners professional team, and that medical Cannabis products will not be prescribed without the agreement of that team. I understand that Big Narstie Medical & Partners provide my GP and other clinicians involved in my care with information regarding my case. I understand that Big Narstie Medical & Partners store my personal and clinical data electronically , and use electronic means to transmit such data confidentially to me, my GP, the pharmacy, and other parties involved in my care. I understand that I understand that Big Narstie Medical & Partners may take photographs or video and/or audio recordings of me while I am in the clinic to help serve as a record of my medical condition, and for audit purposes. These photographs or recordings may be stored confidentially as part of my medical record in paper or digital form. I am entitled to refuse to have such photographs or recordings made. If Big Narstie Medical & Partners wish to use my photographs or recordings for any other purpose, such as research or teaching, they must ask for my permission first, and I am entitled to refuse to give my permission. I give consent for Big Narstie Medical & Partners to release my contact details and prescription details to IPS and Vertical Pharma Resources in order to contact me about my prescription to arrange delivery of my prescribed medication. I will endeavour to be at the address provided on the prescription to receive my Controlled Drug in person, which will be delivered by a courier on behalf of Vertical Pharma Resources Pharmacy. I agree to the above statement.I wish to receive communications from Big Narstie Medical & Partners by:(Required) Email Phone call SMS message WhatsappSelect AllI confirm that the information provided in this medical questionnaire is correct and complete to the best of my knowledge. I understand that failure to provide true and correct information could result in my prescribed medical cannabis being withdrawn by the prescribing specialist. Big Narstie Medical works in partnership with Integro Medical Clinics. By signing below you consent to sharing of your data with Integro Medical Clinics Ltd.Patient Signature(Required)PhoneThis field is for validation purposes and should be left unchanged.
