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Progress Questionnaire 1 Month Review
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Email
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Last Name
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Date of Visit
MM slash DD slash YYYY
Name
(Required)
Age
(Required)
Please enter a number from
18
to
99
.
Gender
(Required)
Male
Female
Start date of Treatment
(Required)
MM slash DD slash YYYY
Treatment Adherence
1. How consistently have you followed your prescribed cannabis treatment over the past month?
(Required)
Every day as prescribed
Most days
Occasionally
Rarely
2. What dosage of medicinal cannabis are you currently taking?
(Required)
Lower than prescribed
As prescribed
Higher than prescribed
3. How often have you used medicinal cannabis?
(Required)
Once a day
Twice a day
Three times a day
As needed
Symptom Management & Treatment Effectiveness
4. What condition are you using medicinal cannabis to treat?
(Required)
Chronic pain
Anxiety
Insomnia
Inflammation
Other
(Select all that apply)
5. On a scale of 1 to 10, how effective has your treatment been in managing your symptoms?
(Required)
1-2
3-4
5-6
7-8
9-10
6. Have you noticed any improvement in your symptoms since starting treatment?
(Required)
Significant improvement
Some improvement
No change
Worsening of symptoms
Side Effects & Adverse Reactions
7. Have you experienced any side effects from medicinal cannabis?
(Required)
Drowsiness
Dry mouth
Dizziness
Increased heart rate
Anxiety
None
(Select all that apply)
8. On a scale of 1 to 10, how manageable have these side effects been?
(Required)
1-2
3-4
5-6
7-8
9-10
9. Have you had any concerns regarding your treatment?
(Required)
Yes
No
Tolerance & Dosage Consideration
10. Tolerance & Dosage Consideration
(Required)
Yes, it remains effective
Yes, but slightly less effective
No, I feel it is wearing off faster
No, I need a higher dose
11. Have you required additional doses outside your prescribed amount?
(Required)
No, I have stayed within my prescribed dosage
Yes, but only occasionally
Yes, frequently
12. How important is it for you to have quicker relief from your symptoms?
(Required)
Very important
Important
Neutral
Not important
Overall Satisfaction & Next Steps
13. How satisfied are you with your treatment so far?
(Required)
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
14. How likely are you to continue with medicinal cannabis as part of your treatment plan?
(Required)
Very likely
Likely
Neutral
Unlikely
Very Unlikely
