Screening Questionnaire

Please fill out the following form to help us understand your compatibility to participate in CCTA study

Welcome to the CANNACEUTICA clinical study - An Observational Study Characterizing the Pain Response, Safety and Tolerability of CCTA320 in Patients with Chronic Pain.

1. Did you purchase or intend to purchase medical cannabis (CANNACEUTICA - CCTA320 product) individually, under your own discretion, using your own funds?
2. Have you been diagnosed by a licensed physician or healthcare provider with chronic pain that has lasted at least 3 months?
3. When you were diagnosed with chronic pain, did you complete a Brief Pain Inventory (BPI) questionnaire?
4. If you answered yes for question 3, was your average overall pain level based on the BPI greater than or equal to 5 (>/=5)?
arrow&v
6. Are you currently taking medications or have you taken medications in the past to treat your chronic pain?
8. Were you diagnosed with cancer and/or are being treated for cancer or have been treated for cancer in the last 12 months?
9. Have you been diagnosed with Fibromyalgia?
10. Do you have a history of substance abuse and addictions (for example drugs, alcohol)? Except cigarette use.
12. Have you been diagnosed with Schizophrenia, affective disorder, and/or been hospitalized for a psychiatric condition?
13. Have you had any psychotic episodes in the past (difficulty determining what is real and not real, delusions, hallucinations)?
14. Do you have a first-degree family member (parent, sibling or child) who has been diagnosed with or experienced psychosis? 
15. Do you use medical cannabis or cannabis for recreational use on a regular basis?
17. Are you currently pregnant or breast feeding?
18. Did you suffer in the past 6 months from myocardial infarction (heart attack)?
19. Do you suffer from Class 3-4 Congestive Heart Failure?
21. Diagnosed with a medical and/or physical condition with an estimated life expectancy of less than 12 months?
22. Any known allergy to cannabis or cannabinoids?
25. How did you hear about the study?

Thank you for filling in the information and submitting the questionnaire! We appreciate your time.

Based on your answers, the research team shall review the information and evaluate if you meet study criteria. Within 14 days, If you meet study criteria, the research team shall reach out and invite you to participate in the study.