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?