Step 2 - Complete Initial Intake Form

The data we collect here will help us develop your treatment plan and should take 5 minutes. Any permissions given can be withdrawn at any time by emailing us and anything you share will never be shared with a third party. 

Patient – Intake 0 LRC Clinic Medical Intake Form

Personal Details



I give LRC permission to store and use information I share to communicate with me and improve my health and wellbeing and I agree to the LRC Terms and Conditions and Privacy Policy
Do you consent to us sharing information with your GP? We may be unable to prescribe certain medications if we are unable to share information with your GP
Do you consent to us sharing your details with pharmacies so they can deliver your medications?
Do you consent to us sharing information with your next of kin if medically necessary?
Are you completing this on behalf of a child?
Are you considering medical cannabis as a treatment option?
Is Chronic Pain a symptom your experience?

Symptoms And Diagnosis

Medical Diagnosis
Main Symptoms

Current Treatments

Other Medical History


Previous Treatments

Tobacco and Alchohol

How many years total smoking history do you have?
How many cigarettes daily did / do you smoke?
If you previously smoked, when did you stop smoking?


Have you ever suffered or suspected you suffered from an eating disorder
Do you have or suspect you have food intolerance or food cravings
Do you follow any specific diet? Click all that apply

Sleep and activity

What physical activities do you do
Do you experience these sleeping issues
Av. daily sweetened drink consumption (including fruit juice, fizzy drinks, sugared tea etc)
eg. If you have 1 fruit juice each day for breakfast each day and 7 fizzy drinks at the weekend, total =14 / 7 = 2
Av. daily alchohol consumption (units)
eg. If you have 1 small wine (2 units) with dinner each week day and 1 bottle (10 units) at the weekend, total = (5 x 2) + 10 = 20 / 7 = 3
Daily Caffeinated drink consumption
Av. daily physical activity and exercise (hours)
Av. Total time in bed each night (hours)
This is the time you get in to bed and close your eyes to the time you get our of bed in the morning.
Av. daily cigarettes smoked
Please rate your sense of purpose and meaning in life
1 is very low and 10 is very high
Daily Vape liquid use (ml)

Opioid Risk Assessment


Is there any history in your family of Alcohol abuse
Is there any history in your family of illegal drug use
Is there any history in your family of prescription medication abuse
Do you have a personal history of Alcohol abuse?
Do you have a personal history of illegal drug use
Do you have a personal history of prescription medication abuse
Do you have a history of pre-adolescent sexual abuse?
Are you aged between 16 and 45
Have you been diagnosed with any of the following:
Have you have been diagnosed with any of the following:
Do you have any parents or siblings with the following diagnoses. Tick all that apply.
Do you have any history of past self harm or suicide attempts?
Have you currently or recently had thoughts about self harm?
Have you ever had a substance use disorder?

Medical Cannabis Assessment

Informed Consent

Legally we have to inform you of current regulations around medical cannabis and its use in your treatment. We have also provided this information in your initial email.

  • As of 2018, Medical cannabis is an unlicensed medicine in the UK.  What this means is that it is not considered a first-line therapy and does not have a licence for any single indication or disease.  It is used for treatment resistant conditions where no licensed medicine available adequately treats their condition.
  • The Physician, the Clinic staff will NOT be provide information regarding any other way of obtaining cannabis other than an approved medical pharmacy 
  • The Physicians will evaluate you for the use of medical cannabis and make recommendation partly on the medical information you have provided. It is your responsibility to ensure that there is no misrepresentation of your medical information.
  • You agree to only use medical cannabis for the treatment of your medical condition as agreed by the Physician and not for recreational or non-medical purposes 
  • Using cannabis is prohibited while driving or performing hazardous tasks such as operating heavy machinery, in safety-sensitive occupations such as health professionals and the supervision of children. Depending on THC dosage and administration, impairment may last over 24 hours following last usage.
  • Compared with recreational use, the incidence of significant side effects from the supervised use of medical cannabis when used as prescribed are low and it is generally well tolerated by most patients.  However, the potential side effects from the use of medical cannabis, usually at higher doses of THC may include, but are not limited to the following; dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, inability to concentrate, impaired motor skills, paranoia, apathy, depression and/or restlessness. 
  • Cannabis products containing THC may exacerbate schizophrenia in persons predisposed to the disorder. 
  • In people with a previous history of psychosis, cannabis containing THC may trigger a psychotic episode and is not recommended.  If you have a history of psychosis or schizophrenia unfortunately you are not eligible for treatment with medical cannabis.
  • You understand that using cannabis while under the influence of alcohol is not recommended and may lead to Additional side effects. 
  • Smoking cannabis may cause respiratory problems and harm, including; bronchitis, emphysema and laryngitis and may increase the risk of respiratory disease and cancer. This method is not endorsed or considered an appropriate use of your medical cannabis. 
  • There are some medications which may be at higher risk of having a significant drug interaction with medical cannabis. If you are taking medication or undergoing treatment for any medical condition, you understand you should consult with your GP and/or treating specialist  and inform them that you are also taking medical cannabis.  If you have started a new medication since your last visit to the Clinic, you should inform the clinic so that this can be updated in your medical history so our doctors are aware.
  • Individuals may develop a tolerance to medical cannabis containing THC. If you develop signs of withdrawal which can include; feelings of depression, irritability, insomnia, restlessness, loss of appetite, trouble concentration, sleep disturbance and unusual tiredness, contact the Clinic or your GP.
  • Cannabis overdose is rare and non-fatal.  However, if you are concerned that you may have taken an overdose of your medical cannabis and are experiencing symptoms such as disturbance in heart rhythm, numbness in hands, feet, arms or legs, anxiety attacks and incapacitation, call 999.
  • Medical Cannabis products are used as an adjunct to standard of care treatment where deemed appropriate to help with your symptoms/condition and the Clinic and its  Physicians do not advocate cannabis as a cure for any diseases.

I understand that the information I have been asked to provide is for the diagnosis and treatment of the medical condition for which I want to access that if I have not accurately and completely disclosed the requested information, it may adversely impact the physicians ability to diagnosis my condition and recommend appropriate medical cannabis treatment. 

I have read and agree to the terms and consent to treatment


Previous treatments

UK regulations require previous treatments to have been tried before medical cannabis can be legally prescribed. 



Please confirm that you have previously tried at least 2 treatments for your symptoms
Have you previously tried cannabis and found it helpful for your symptoms?
Do you have any unstable cardiac (heart) problems?
Do you have any history of known anaphylaxis allergy to the cannabis plant or similar plants
Do any of the following apply to you currently or in the last 12 months? Please check all that apply

Current Cannabis Use

Are you a current or previous UK prescribed medical cannabis patient?
Other Cannabis Use
How often do you use cannabis currently?
How do you use cannabis?
How many grams of cannabis flower do you currently use per day (if known)

Please upload a copy of your ID 

Maximum file size: 50MB