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Home
Shop
Animals
Beverages
Cosmetics
Edibles
Inhalers
Medicinal Plants
Pre-Rolls
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Pre Appointment Questionnaire
Health History Questionnaire
Personal information
Name
*
Name
First
First
Last
Last
Date of Birth
*
SA ID Number
*
Marital status
*
Occupation
*
Phone Number
*
Email Address
*
Address
*
Health History
Weight (kg)
*
Height (cm)
*
Chronic illnesses:
*
Medical condition/s you are applying for
Date diagnosed
*
Stage, severity, prognosis if applicable
*
Pain rate 1-10 in severity
*
1
2
3
4
5
6
7
8
9
10
plus1
Add
minus1
Remove
Concerning this diagnosis
Have you seen specialists, where you admitted to hospital, and what tests where done (blood/x-rays/scans etc)?
Year
*
Type
*
Outcome/ result
*
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Add
minus1
Remove
List your prescribed drugs
For this condition, please list your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers and alternative treatments like herbs etc (also list any medication you tried before but stopped because it didn’t work or due to side effects or allergies)
Name the Drug
*
Strength and frequency
*
Using/stopped and why?
*
plus1
Add
minus1
Remove
Allergies to medications
Name the Drug
*
Reaction You Had
*
plus1
Add
minus1
Remove
Please list all medications, prescribed, vitamins, herbal etc for your other medical problems.
Name the Drug
*
Strength and frequency
*
Disease/condition it is for
*
plus1
Add
minus1
Remove
Mental Health
Have you ever had a psychotic episode?
*
No
Yes
Do you feel depressed/stressed? Does this condition affect it?
*
No
Yes
Do you panic when stressed?
*
No
Yes
Do you have problems with eating or your appetite? Does this condition affect it?
*
No
Yes
Do you cry frequently?
*
No
Yes
Have you ever attempted suicide?
*
No
Yes
Have you ever seriously thought about hurting yourself?
*
No
Yes
Do you have trouble sleeping? Does this condition affect it?
*
No
Yes
Have you ever been to a counselor?
*
No
Yes
Do you smoke?
*
No
Yes
How many?
*
How many years?
*
Do you use any illicit drugs?
*
No
Yes
What drugs?
*
How often?
*
Do you drink alcohol?
*
No
Yes
How many drinks per day/week?
*
Does this condition affect you in any way, concerning, social interaction with friends or family, or does it affect you recreationally (your sport or hobbies etc) or affect your work? If yes, please explain.
Any other important information you might think is necessary? You may attach any results or reports etc to this file
File Upload
Drop a file here or click to upload
Choose File
Maximum file size: 52.43MB
Section B
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
Skin
Head/Neck
Ears
Nose
Throat
Lungs
Chest/Heart
Back
Intestinal
Bladder
Bowel
Circulation
Recent changes in: Weight
Recent changes in: Energy level
Recent changes in: Ability to sleep
Other pain/discomfort
Explain symptom:
If you are human, leave this field blank.
Submit
Δ
#-- Display Crossed Out Price for a specific Wholesale Role --# function hide_cart_item_price_for_specific_role( $wholesale_price_html, $price, $product, $user_wholesale_role, $wholesale_price_title_text, $raw_wholesale_price, $source, $wholesale_price ) { global $wc_wholesale_prices_premium; $user_wholesale_role = $wc_wholesale_prices_premium->wwpp_wholesale_roles->getUserWholesaleRole(); $role_to_show_price = 'wholesale_customer'; if ( ! in_array($role_to_show_price, $user_wholesale_role) ) { $wholesale_price_html = '
' . $wholesale_price_title_text . '
'. $wholesale_price .'
'; } return $wholesale_price_html; } add_filter('wwp_filter_wholesale_price_html', 'hide_cart_item_price_for_specific_role', 10, 8 );
