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GreenValleyWellness–OurProcess

ThankyouforconsideringGreenValleyWellness.We’rededicatedtoassistingyouwithobtainingyourlegalauthorizationthroughtheAccesstoCannabisforMedicalPurposesRegulations(ACMPR).

Asmedicalcannabispatientsourselves,weareawareofthedifficultiesthatpatientsfacewhentalkingtotheirPhysiciansaboutmedicalcannabis.Thisiswhyweareheretohelp!

WetrytokeeptheprocesssimpleforeverypatientacrossCanada.

Ourinitialconsultation,whereweassessanddetermineyourpotentialeligibility,isalwaysfree.Theinitialconsultationcanhappeninouroffice,onSkypeoroverthephone.

Duringtheconsultation,ourPatientEducatorswilldothefollowing:

§ � DetermineifyoumaybeeligibleformedicinalcannabisthroughtheACMPR§ � DiscussthedifferencebetweenTHC/CBDandSativa/Indicastrains§ � Discussdosage,titrationandtreatmentplansforeachpatient§ � TalkaboutthelegallyauthorizedLicensedProducerswithintheACMPR§ � DiscusshowyoucanproduceyourowncannabisthroughtheACMPR§ � DiscussifyoucouldbenefitfromanyotherWellnessServicesofferedatourlocation

Inorderforyoutoqualify,youwillneedtoinclude“supportingdocuments”thatoutlineproofofyourmedicaldiagnosis.Examplesofdocumentsthatcanbeacceptedinclude:

§ Awrittenletterofdiagnosisfromahealthcarepractitioner(Physician,PhysicianSpecialist,NursePractitioner,Naturopath,Chiropractor,Physiotherapistetc.)

Ifyoudonothaveaccesstoyourmedicalrecordsordonottakepharmaceuticals,wecanassistyouwitharranginganassessmentwithaqualifiedindividualtoobtainanofficialdiagnosisofyourmedicalcondition(s).

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GreenValleyWellness–OurProcessPage2

Onceyouhavecompletedtheapplicationpackage,youmaydropitoffinpersonorscanthecompetedapplicationpackageandemailitbacktoinfo@gvwellness.cawiththe“supportingdocument”aswellasacopyofValidpictureID.(DriversLicense,PassportorAgeofMajorityCardisaccepted.HealthCardsarenot.)

Duringthistime,wewilldiscusswhichLicensedProducerthatyouwouldliketopurchaseyourmedicalcannabisfrom.WewillalsoassistwithregistrationfortheLicensedProducer.

Wewillrequire50%oftheconsultingpackagefee,previoustoarrangingtheconsultationwiththePhysicianSpecialist/Physician/NursePractitioner.TheremainingbalancewillbedueafteryourconsultationwiththePhysicianSpecialist/Physician/NursePractitioner.*( FeesdonotapplytosmallconsultingpackagesforpatientswithCancer,CRPS,MSorforVeterans,SeniorsandFirstResponders.)OncealldocumentsareforwardedtothePhysicianSpecialist/Physician/NursePractitioner,theywillreviewtheinformationtoseeifyouqualify.Onceapproved,thedateandtimeoftheconsultationwillbesetandcommunicatedtoyou.

AftertheconsultationwiththePhysicianSpecialist/Physician/NursePractitioner,theywillsigntherequiredmedicaldocumentandsendittotheLicensedProducerthatyoupicked.YouwillthenofficiallybecomealegallyauthorizedmedicalcannabispatientinCanada!

Ifyouareapatientwhowillbeproducingyourownmedicalcannabis,wewillarrangeforyoutoreceivetheadditionalmedicaldocumentandassistyouwiththepaperworkrequiredbyHealthCanada.HealthCanada’sprocesswilltakeseveralmonthsforyoutobeapprovedtolegallyproduceyourmedicine.GreenValleyWellnessadvisesnottobeginproducingmedicalcannabisuntilafterHealthCanadahasapprovedyourapplicationforproduction.

Ifyouhaveanyquestionsorconcerns,youmaycontactusatanytime.ThankyouonceagainforchoosingGreenValleyWellnessandwelookforwardtoassistingyou!

PATIENTINFORMATION

Patient’sName:___________________________________________DateofBirth:_____________________________

Address:_______________________________PostalCode:____________City/Prov.:____________________________

Phone#:________________________________________________E-Mail:______________________________________________________________

SkypeUsername:_________________________________________ReferredBy:________________________________________________________

PATIENTMEDICALINFORMATION

*PleaseattachanymedicaldocumentsorothersupportingdocumentswithyourmedicaldiagnosisMedicalDiagnosis:____________________________________________________________________________________

RequestedGramsPerDay:_____________________________________________________________________________

PreferredLicensedProducer:__________________________________________________________________________

PATIENTASSESSMENT

Whatsymptomsapplytoyourcurrentmedicalcondition(s)? *Pleasecheckalltheboxesrelatedtowhatyouexperienceduetoyourmedicalcondition(s)

AbdominalPain DifficultySleeping MuscleSpasms Anxiety Fatigue Nausea BackPain FootPain NeckPain ChronicPain Headaches Seizures Constipation HipPain Shaking Depression LowEnergy VisionIssues Diarrhea MenstrualPains Weakness DifficultyEating MobilityIssues WeightLoss

_________________________________________ _________________________________PATIENTSIGNATURE DATE

AreyouaVeteran?Yes Willyoubeproducingyourownmedicine?YesDesignatedGrower?Yes

PatientConsenttoDisclosePersonalHealthInformation(PHI)Form

Patient’sName:___________________________________________DateofBirth:_____________________________

Address:_______________________________PostalCode:_________City:_____________________Prov.:__________

Phone#:_____________________________________ E-Mail:___________________________________________

I,____________________________,consenttothereleaseofpersonalhealthinformation(PHI)toGreenValleyWellnessbywayofunsecuredemail/Skype.IalsorecognizethatotheroptionshavebeenmadeavailabletomebywayoffaxingmypersonalhealthinformationdirectlytotheofficeofthePhysicianSpecialist/Physician/NursePractitioner,towhichIamhavingmymedicalassessment.Iunderstandthatsendingpersonalhealthinformationthroughunsecureemailisnotnecessarilyatahighriskofdiversion,butthisriskissubstantiallyloweredwhensendingpersonalhealthinformationbywayoffax.IauthorizeGreenValleyWellnesstosharemypersonalhealthinformationwiththePhysicianSpecialists/Physicians/NursePractitionersclinictowhichIwishtohaveanassessmentandanyotherpartiesinvolvedwiththeprocessofobtainingmyMedicalDocument.IunderstandthepurposefordisclosingthispersonalhealthinformationtoGreenValleyWellnessandIunderstandthatIcanrefusetosignthisform.IherebyreleaseGreenValleyWellness,theassessingPhysicianSpecialist/Physician/NursePractitioner,his/herclinic,myfamilyPhysicianandanyotherinvolvedPhysicians/partiesfromanyandallactions,claims,causesofactions,complaints(evenbyfamilyandfriends)anddemandsfordamages,loss,orinjurywhatsoeverarisingdirectlyorindirectlyasaconsequencetomyuseofmedicalcannabisandmyapplicationtopossessand/orproducemedicalcannabis.

SIGNATURE:___________________________________ DATESIGNED:_____________________________

Release,Acknowledgement&IndemnityForPatientsseekinganACMPRMedicalDocumentI,______________________________,understandthatthisReleaseandAcknowledgementcontainsvaluableinformationaboutpossessing/cultivatingandconsumingprescribedmedicalcannabisandthattheassessingPhysicianSpecialist/Physician/NursePractitionerrequiresittoissueamedicaldocumentfortheAccesstoCannabisforMedicalPurposesRegulations(ACMPR).IalsounderstandthattheconsultingPhysicianSpecialist/Physician/NursePractitionerwillnotnecessarilybeassumingprimarycareforme,butonlyberecognizedasmyACMPRprescribingPractitioner.IunderstandandagreetocontinuetoregularlyseemyprimarycarePhysicianformymedicalconditionsonaregularbasisandnotifythemofmymedicaluseofcannabis.ThePhysicianSpecialist/Physician/NursePractitionerwillweightherisksversustherewardsintreatingmymedicalcondition(s)andanyassociatedsymptoms,withmedicalcannabis.IconfirmthattheassessingPhysicianSpecialist/Physician/NursePractitionerwillbetheonlypractitionerprovidingamedicaldocumentundertheACMPRforthepurposeofpossessing/cultivatingandconsumingmedicalcannabis.IagreetomakenoclaimsorcommenceanylegalactionagainstGreenValleyWellness,theassessingPhysicianSpecialist/Physician/NursePractitioner,myfamilyPhysicianoranyotherinvolvedPhysicians/partiesinregardsto:a) MyconsumptionofmedicalcannabisfromtheLicensedProducersorcultivatedbymyselfb) MyApplicationormedicaldocument(s)forpossessing,obtaining,cultivatingandconsumingmedicalcannabisIamawarethatPhysicianSpecialists/Physicians/NursePractitionersgenerallyagreethatmedicalcannabis:-Mayeffectsight,soundsandtouch-Mayimpairthinking,problem-solving,coordination,memoryandlearning-Mayincreaseheartrateandreducebloodpressure-Mayinduceanxiety,fear,distrust,orpanicIamawarethatmedicalconditionssuchasschizophrenia,atrialfibrillation,Heartattack/strokeoruseofbloodthinnersmayresultinadenialformyapplicationtopossessandconsumemedicalcannabis.Iamalsoawarethatifpregnant,orplanningtobecomepregnant,thatmedicalcannabisshouldnotbeconsumedduringpregnancyorwhilebreastfeeding.IamawarethatwhilepurchasingmymedicalcannabisfromaLicensedProducerorproducingmyownmedicalcannabisislegal,IagreethatIwillnotresellmymedicalcannabis.

FOR PATIENTS Pursuing an ACMPR Medical Document I am aware of the considerable debate and a lack of consensus among Physician Specialists/Physicians/Nurse Practitioners about; -Theappropriatedoseandmedicaluseofcannabis-Therisksofburningmedicalcannabisascomparedtovaporizingoringesting-Therisksofburningextractedcannabinoidssuchasoilsorhashish-Thelongtermpsychologicalandhealthrisksassociatedwithmedicalcannabis-Theriskofpulmonaryinfectionsandrespiratorycancer-Theriskoftriggeringmentalillness,suchasbipolardisorderandschizophrenia-Theriskofnauseaanddisorientation

IconsenttothedisclosureandsharinganduseofmypersonalinformationandpersonalhealthinformationbywayofunsecuredEmail/Skype,bytheassessingPhysicianSpecialist/Physician/NursePractitioner,GreenValleyWellness,myLicensedProduceroranypartiesinvolvedwiththeprocessofobtainingmyMedicalDocument.Theinformationmaybeusedtocontactandregisterthepatient.Theinformationmayalsobeusedforanalyticalandresearchpurposes.

Itrulybelievethattreatingmypersonalmedicalcondition(s)withmedicalcannabis,canpotentially,orhashad,apositiveeffectandthebenefitsoutweightherisksassociated.ThisismypersonaldecisiontopossessandconsumemedicalcannabisandIdonotsupportanyclaimsmadebyfamily,friendsorotherindividualsagainstGreenValleyWellness,theprescribingPhysicianSpecialist/Physician/NursePractitionerandanyotherpartiesinvolvedwiththeprocessofobtainingmyMedicalDocument.

IherebyreleaseGreenValleyWellness,theassessingPhysicianSpecialist/Physician/NursePractitionerandanyotherpartiesinvolvedwiththeprocessofobtainingmyMedicalDocument,fromanyandallclaims,actions,causesofactions,complaints(includingfriendsandfamily)anddemandsfordamages,loss,orinjuryarisingdirectlyorindirectlytomyuseofmedicalcannabisandmyapplicationtopossess,cultivateorconsumemedicalcannabis.

Thisreleasefromliabilityistobebindingonheirs,executorsandsignsandIacknowledgethatIhavetherighttorefusetosignthisform.

Ifyoudriveavehicleontheroadoroperatemachinery,doNOTdoso:1. Within4(FOUR)hoursofinhalingcannabisvapourorsmoke,2. Within6(SIX)hoursofeatingoringestingcannabisediblesoroil,3.Within8(EIGHT)hoursofusing,ifyougeteuphoricordizzy-"Stoned"Remembertokeepallcannabisproducts,andmedicines,inaLockedBox.

PRINTNAME:_____________________________WITNESSPRINTNAME:______________________________

SIGNATURE:______________________________SIGNATURE:_______________________________________DATESIGNED:_____________________________DATESIGNED:______________________________________

BriefPainInventoryName: Date:

1. Throughoutourlives,mostofushavehadpainfromtimetotime(suchasminorheadaches,sprainsandtoothaches).Haveyouhadpainotherthantheseeverydaykindsofpaintoday? Yes No2. Onthediagram,shadeintheareaswhereyoufeelpain.PutanXontheareathathurtsthemost.

3. Pleaserateyourpainbycirclingtheonenumberthatbestdescribesyourpainatitsworstinthepast24hours.012345678910NoPain Painasbadasyoucanimagine4.Pleaserateyourpainbycirclingtheonenumberthatbestdescribesyourpainatitsleastinthelast24hours.012345678910NoPain Painasbadasyoucanimagine5.Pleaserateyourpainbycirclingtheonenumberthatbestdescribesyourpainonaverage.012345678910NoPain Painasbadasyoucanimagine6.Pleaserateyourpainbycirclingtheonenumberthatbestdescribeshowmuchpainyouhaverightnow.012345678910NoPain Painasbadasyoucanimagine8. Inthepast24hours,howmuchreliefhavepaintreatmentsormedicationsprovided?Pleasecircletheonepercentagethatmostshowshowmuchreliefyouhavereceived.0%102030405060708090100%NoRelief CompleteRelief9. Circletheonenumberthatdescribeshow,duringthepast24hours,painhasinterferedwithyour:a)GeneralActivity012345678910

Notatall GreatlyInterferesb)Mood012345678910Notatall GreatlyInterferesc)Walkingability012345678910Notatall GreatlyInterferesd)NormalWork(includesbothworkoutside/home/housework)012345678910Notatall GreatlyInterferese)Relationswithotherpeople012345678910Notatall GreatlyInterferesf)Sleep012345678910Notatall GreatlyInterferesg)Enjoymentoflife012345678910Notatall GreatlyInterferesh)Abilitytoconcentrate012345678910Notatall GreatlyInterferesi)Appetite012345678910Notatall GreatlyInterferes10. Intheareawhereyouhavepain,doyouhave“pinsandneedles”,tinglingorpricklingsensations? Yes No11. Doesthepainfulareachangecolour(perhapsmottledorred)whenthepainisparticularlybad? Yes No12. Doesyourpainmaketheaffectedskinabnormallysensitivetothetouch? Yes No13. Doesyourpaincomeonsuddenlyandinburstsfornoapparentreasonwhenyouarecompletelystill? Yes No14. Intheareawhereyouhavepain,doesyourskinfeelunusuallyhotlikeburningpain? Yes No15. Gentlyrubthepainfulareawithyourindexfingerandthenrubanon-painfularea.Howdoestherubbingfeelinthepainfularea?

NodifferenceDiscomfort–pinsandneedles,tinglingor

burninginthepainfularea16. Gentlypressonthepainfulareawithyourfingertipthengentlypressinthesamewaytoanonpainfularea.Howdoesthisfeelinthepainfularea?

NodifferenceDiscomfort–pinsandneedles,tinglingor

burninginthepainfulareaModifiedfromMcCafferyM,PaseroC:Pain:Clinicalmanual,p61,1999,Mosby,Inc.FromPainResearchGroup,DepartmentofNeurology,UniversityofWisconsin-Madison.BennettMI2001PAIN92:147-157

Time:

Generalized Anxiety Disorder 7-item (GAD-7) scale

Over the last 2 weeks, how often have you been bothered by the following problems?

Not at all sure

Several days

Over half the days

Nearly every day

1. Feeling nervous, anxious, or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it's hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen

Add the score for each column

Total Score (add your column scores) =

0 1 2 3

+ + +

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all __________ Somewhat difficult _________ Very difficult _____________ Extremely difficult _________ Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.

PatientHealthQuestionnaire(PHQ-9)

Name:______________________________________________________Date:_____________________________

Overthelast2weeks,howoftenhaveyoubeenbotheredbyanyofthefollowingproblems?

Notatall

Severaldays

Morethanhalfthedays

Nearlyeveryday

1.Littleinterestorpleasureindoingthings 0 1 2 3

2.Feelingdown,depressed,orhopeless 0 1 2 3

3.Troublefallingorstayingasleep,orsleepingtoomuch 0 1 2 3

4.Feelingtiredorhavinglittleenergy 0 1 2 3

5.Poorappetiteorovereating 0 1 2 3

6.Feelingbadaboutyourself–orthatyouareafailureorhaveletyourselforyourfamilydown 0 1 2 3

7.Troubleconcentratingonthings,suchasreadingthenewspaperorwatchingtelevision 0 1 2 3

8.Movingorspeakingsoslowlythatotherpeoplecouldhavenoticed?Ortheopposite–beingsofidgetyorrestlessthatyouhavebeenmovingaroundalotmorethanusual

0 1 2 3

9.Thoughtsthatyouwouldbebetteroffdeadorofhurtingyourselfinsomeway 0 1 2 3

Forofficecoding:TotalScore_______=______+______+______

TotalScore______

Ifyoucheckedoffanyproblems,howdifficulthavetheseproblemsmadeitforyoutodoyourwork,takecareofthingsathome,orgetalongwithotherpeople?

Notdifficultatall Somewhatdifficult Verydifficult Extremelydifficult

Name:_______________________________Date:_________________________________BirthDate:____________________________Height:____________Weight:__________

MedicalCannabisAssessment

Doyoucurrentlyusemarijuanaforrelief? No YesIfYESabove,howmanytimesadaydoyouuseit?____________________________________Howlonghaveyouuseditmedically?______________________________________________Whendidyoulastuseit?________________________________________________________Ifyoudonotobtainaprescriptionformarijuana,willyoucontinuetouseit?NoYes

Doyousmoketobacco? No Yes-cigarettes,cigars,pipe-numberperday._________

Doyouusemedicinescontainingopiates?(Codeine,morphine,other) No YesIfYes,whichonesdoyouuse,howoftenandwhatdosage?____________________________

Doyouusecocaineorother"street"drugs?No YesIfYes,whichonesdoyouuseandhowoften?________________________________

Areyouallergictoanymedicine? No YesIfYes,pleaselistthemedicationsyouareallergictoanddescribethereaction:

FamilyHistory:Isyourfatheralive?

No YesIngoodhealth? If"No"-causeofdeath

Isyourmotheralive?

No Yes Ingoodhealth? If"No"-causeofdeath

Doyouhavesiblings? No Yes (Pleaselistages,gendersandstatesofhealth)

Doanyofyourfamilymemberssufferfrompsychiatricdisorders?No YesIfYes,whichfamilymemberandwhatcondition(s)?___________________________________

CAGEQUESTIONNAIRE

1. Haveyoueverfeltyoushouldcutdownonyourdrinking?Yes No2. Havepeopleannoyedyoubycriticizingyourdrinking? Yes No3. Haveyoueverfeltbadorguiltyaboutyourdrinking? Yes No4. Haveyoueverhadadrinkfirstthinkinthemorningtosteadyyournervesorgetridofa

hangover(eye-opener)?YesNo

List All Medications Info from home medication list (as identified from intake history, patient, family, prescription bottle)

Drug Name Dose Frequency Route of Administration

PleaselistanymedicationsyoutookthatFAILEDtohelpgiveyourelief:

SocialHistory:Areyou:single,married,divorced,other(pleasecircleone).

Doyouresideina:house,apartment,sharedspace,institution,nofixedaddress(pleasecircleone).

Wholiveswithyou?(Wife,husband,partner,noone)(pleasecircleone).

Ifchildrenareinyourdwelling,pleaselistthemandtheirages:

HistoryofOperations-Surgeries/Trauma:Pleaselistanysurgeryyouhavehadandtheyear.

PsychologicalHistory:(Pleasecircleapplicablediagnosisbelow)

Doyousufferfrom:AnxietyDepressionInsomniaBipolardisorderOCD

Whatyeardidtheconditionbegin?______________.

Haveyoubeenhospitalizedforanyofthese?NoYes(Ifyes,whatyear)____________.

Haveyouhadanythoughtsofself-harmorsuicide?NoYesIfYES,Pleaseprovidedateoflastthought/Selfharm.____________Pleaseprovidegeneralexplanation.____________________________________________________________________________________________________________________________________________________________________Areyouoftenconfused?NoYes

ReviewofSystems(IfYes,pleaseexplain)

Doyouhaveanyproblemswithsenses(smell,taste,sight,hearingortouch)?No Yes

Doyouhaveanyproblemswithyourheadorneck?No Yes

Doyouhaveanyproblemswithbreathingorlungdiseases? No Yes

Doyouhaveheartorcirculationproblems?No Yes

Haveyoueverhadaheartattack? No Yes

Doyouhaveproblemsclimbingstairsorexercising? No Yes

Doyouhaveanyeating,swallowing,digestionorproblemswithbowels?No Yes

Doyouhaveanyproblemswithyourkidneys,bladderorurination? No Yes

Pregnancy:Areyoupregnantnowormightyoubecomepregnantinthenearfuture?NoYes

Doyouhaveproblemswithyourmusclesorjoints?NoYesIfyes,pleaseindicatewhichjointsormusclesarebotheringyou.

Doyouhaveanyswellinganywhere? No Yes

Signatureofpatient:____________________________________________