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Your Name:

Date of Birth:

What is your current pain level?

🔴 Severe Pain 🟠 Moderate Pain 🟡 Mild Pain 🟢 No Pain

Have your symptoms changed since starting medical cannabis?

📉 Worsened ➖ Unchanged 📈 Improved

How would you describe your sleep quality?

🌙 Poor Sleep 🌕 Good Sleep 🌞 Excellent Sleep

How effective is your treatment in managing symptoms?

❌ Not effective ⚖️ Somewhat effective ✅ Very effective

What specific improvements have you noticed? (Select all that apply)

👍 Pain relief 🌙 Better sleep 😊 Improved mood

Which side effects are you experiencing? (Select all that apply)

😵 Dizziness 💤 Fatigue 😬 Dry mouth ❌ No side effects

How has your mood changed?

😞 Worse 😐 Unchanged 😊 Improved

Acknowledge and Sign:

Medical Cannabis Follow-Up Consultation