0 RM Clinics Intake Form

Resilience Medicine Clinics (RMC) Intake

Welcome. 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 Any permissions given can be withdrawn at any time by emailing us and anything shared will never be shared with a third party. Privacy Policy Terms

I agree to the RMC Terms and Conditions and Privacy Policy
I give RMC permission to store and use the information I share in this form to communicate with me, and to care for my wellbeing.
Sex
Are you considering medical cannabis as a treatment option?
Is pain a symptom you experience?

Integrative Medical History

Current Treatments

Previous Treatments

Have you ever suffered or suspected you suffered from an eating disorder
How many caffeinated drinks per day do you drink
How many sweetened do you drink per day (including fruit juice and fizzy drinks)
Do you have or suspect you have food intolerance or food cravings
Do you currently smoke cigarettes or use products containing nicotine including vape pens?
If yes, how much do you vape / smoke each day?
Have you previously smoked?
How many years did you smoke for?
When did you stop smoking?
How much did you smoke each day?
 

PHYSICAL ACTIVITY, FUNCTION AND REST

What physical activities do you do
How much activity do you do each week
Please rate the quality of your sleep
Do you experience these sleeping issues
Please rate yourself on a scale of 1 (low) to 5 (high): Having a sense of purpose and meaning in your life

QUICK RESILIENCE ASSESSMENT

The following 4 short questions help us understand your current wellbeing and quality of life and resilience level so we can track how things are going over time.

Please answer these questions in relation to how you have felt in the last 7 days with 10 being the best and 1 being the worst.

Please rate your mood
Please rate your energy
Please rate your mental clarity (ability to focus v brainfog)
Please rate your ability to feel calm (stress and anxiety)
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
Please tick if 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?