Assessment Form

Eligibility Assessment

By submitting my application, I understand that elios clinics will receive my information and may reach out to me via phone, email, or SMS regarding my treatment. *

I consent to receiving emails communication and updates from elios clinics on a regular basis. *

Account Information

Are you completing form on behalf of some one else? *

NoYes

Please enter your Name *

Your relationship with the patient? *

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Title *MrMissMrsMsMxDrMasterOther

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Other *

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First Name *

Last Name *

Date Of Birth *

Gender *FemaleMaleAFABAMABSpecify

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Are you currently pregnant? *

YesNo

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Specify *

Email Address *

Phone Number *

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Address *

Street address *Street address line 2

City *

State

Postcode *

Country *Please selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

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Where did you hear about us? *My doctor or healthcare professionalRecommended by a patient of Elios ClinicsPodcast / RadioGoogle SearchSocial MediaPress / TVLocal PharmacyOther (please specify below)

Other (Please Specify) *

What days are prefered for a Consultation booking? *

Weekday (Monday to Friday)Weekend (Saturday and Sunday)

What Times are prefered for a Consultation booking? *

Mornings (9am to 12pm)Lunch Time (12pm to 2pm)Afternoons (2pm to 6pm)Evenings (6pm to 9pm)

About your health

Do you have any allergies? *

YesNo

Please specify your allergies: *

Reason you would like to be considered for treatment *

CancerPainPsychiatricDermatologyGastrointestinal ConditionNeurological ConditionsOther (please specify below)

Reason for treatment *

Have you been referred to medical/surgical specialist in a hospital for the condition stated above? *

YesNo

If yes, please state what treatment was offered or undertaken? *

Have you tried at least 2 medicines / therapies to alleviate the symptoms above? *

YesNo

Medication/Treatment 1 *

Medication/Treatment 2 *

Other Medications/Treatments

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Rate the following on a scale of 0-10, with 0 indicating no symptoms/impact, and 10 indicating severe symptoms/impact on your life

Pain score *

012345678910

Sleep score *

012345678910

Mood score *

012345678910

Anxiety score *

012345678910

Quality of life score *

012345678910

Medical Conditions

Do you have any other medical conditions? (these include but not limited to Heart conditions, liver conditions, cancer treatments) *

YesNo

Please specify the medical conditions *

Are you taking any other medication? *

YesNo

Please list the medication *

Have you ever been referred to a psychiatrist or community mental health services? *

YesNo

Will you please provide more details

Do you have any history of drug abuse or dependency (prescription or recreational)? *

YesNo

Will you provide more details

Are you taking any over the counter supplements (including products containing CBD)? *

YesNo

Please list supplements *

Do you already use Cannabis (recreational/medicinal)? *

Yes No

Form of Cannabis you use?

Cannabis Flower (bud)THC OilsCBD OilsTHC VapeCBD VapeEdiblesOther

How much do you take? (grams/ml) *

Strain type/specific? (i.e Cheese) *

How much THC does it contain? (mg) *

How much CBD does it contain? (mg) *

Do you find it beneficial and what affects does it have? *

GP information

GP Name *

GP Email Address *

GP Telephone *

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GP Address *

Medical Centre/GP surgery name *Street address *

City *

State

Postcode *

Country *Please selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

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Your Next of Kin *

Next of Kin contact (Phone Number) *

Are you seeing a specialist consultant?

YesNo

Specialists Name *

Are you coming from another medical cannabis clinic?

YesNo

Name of the clinic *

You Medical Records

Select option *

I will provide summary of my NHS records I would like Elios clinics to request my summary care records

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Upload your medical records *

Browse

Description of files needed (screen shot of NHS records, Downloaded report from NHS APP or Website, Records from GP, Letters from GP, Letters from Consultants, any other information that relates to your medical condition and history). You can add multiple files.

Would you like to provide any other files *

Browse

You can add multiple files

Consent

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I consent for Elios clinics to obtain my medical records and accept Terms and Conditions *

Your Signature *

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Date *

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