Alternative Therapy Questionnaire Form

Patient (full name) *

Date of birth *

Address *

Questions – please answer

What is the primary diagnosis or medical condition for which you seek treatment with alternative therapy? *Chronic painAnxiety, depression, or Chronic insomniaChemotherapy-induced nausea and vomitingMigraine / EpilepsyNeuropathic painCancer / palliative painOther

Have you ever self-medicated or are currently self-medicating with alternative therapy? *YesNo

Are you pregnant, breastfeeding, or considering pregnancy? *YesNoNot applicable

What other treatment have you tried for the condition? *

What medications have you previously used? List any side effects and your reason for stopping. *

Do you currently experience, or have a history of the following? *PsychosisMood disorder or severe anxietyDrug dependence or substance abuseBipolar disorderCardiovascular disease

Patient Declaration – please choose Yes or No

I confirm that my doctor has provided me with information about alternative therapy product, its concentration, its dosage, how to use it, who to take it, how to store the alternative therapy product and the proposed duration of treatment. *Alternative therapy is stored at room temperature away from sunlight. *YesNo

I understand that the prescribing doctor will report my treatment outcomes to the government. *YesNo

I understand that the cost of alternative therapy is solely my responsibility. *YesNo

I understand that I must not drive or operate machinery whilst taking alternative therapy. If I drive or operate under these circumstances, I am breaking the law. I understand that a legally issued prescription does not provide a defence to such an offence in the court of law. *YesNo

I understand that risks and complications associated with alternative therapy treatment. I agree to follow my doctor’s recommendations regarding dosing. I agree to report any adverse effects I experience from taking alternative therapy, including but not limited to changes in level of sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhoea, drowsiness, dizziness disorientation, agitation, balance problems, changes in memory, paranoid delusions or hallucinations. *YesNo

I understand that there is a possibility of unknown risk and side effects. *YesNo

I understand that alternative therapy might interact with my other medications, and doses may need to be adjusted accordingly. *YesNo

I agree to attend regular follow-up consultations in the clinic or over the phone as directed by my doctor and with other healthcare providers. *YesNo

I agree to keep a log of my doses and changes in symptoms due to alternative therapy. *YesNo

I agree that I will not use any form of cannabis other than that prescribed by my doctor, including any illicit form of cannabis (marijuana). *YesNo

I agree to notify my prescribing doctor of any changes in my other medications. *YesNo

I agree to share my clinic outcomes for research purposes. *YesNo

I agree to undertake regular blood tests and to avoid the use of alcohol or any use of illicit and unprescribed drugs. *YesNo

Date *

Patient’s signature *

Treat Clinic acknowledges the Traditional Custodians of the land in which we work on. We acknowledge the Traditional Custodians of Country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past, present and emerging, and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

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Alternative Therapy Questionnaire Form

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info@treatclinic.com.au