Date

Patient Name (required)

Date of Birth (required)

Address (Required)

Zip Code

Phone Number

Email (required)

Primary Care Physician

Primary Phone Number

Pharmacy Name

Pharmacy Address

Pharmacy Number

In Case of Emergency Name (Required)

Relationship (Required)

Address (Required)

Phone Number (Required)

Referring Physician

Past Medical History

Hospitalizations - Date and Illness/Reason

Surgeries - Date and Type, including any body implants such as cardiac stents, heart valves, joint replacements, pacemakers

Ongoing Medical Problems, including asthma, COPD, diabetes, heart disease, heart murmur, hepatitis, HIV/AIDS, hypertension, kidney failure, venereal disease, alcohol or drug addictions, present or previous psychiatric care

Alergies - Name Drug and Reaction, including any type of anesthetic

Clinical History and Condition

Indication(s) for Cannabis Treatment
Chief complaint for evaluation of cannabis treatment

List of Symptoms - Type/ Frequency/ Severity

Prior Treatment(s), Duration and Outcome of Treatment

RX Medication Name/ Dosage/ Regimen/ Target Symptom

Are you currently taking Aspirin, Coumadin, Plavix, Persantine, or other blood thinners?

Preventative Care -List Ongoing Medical Treatments, Special Diets, Physical Therapies, etc.

If Female, are you currently pregnant or think that you may be? YES/NO

Date of last menstrual cycle

Are you planning on getting pregnant? YES/NO

Are you currently breast-feeding? YES/NO

Family Medical History

Hereditary diseases, significant illnesses or cause of death of Grandparents/Parents/Children/Siblings/Aunts/Uncles/Cousins, example allergy/bleeding disorders/cancer/heart disease/sickle cell/ anemia/ psychiatric problems such as anxiety/bi-polar/depression, etc.

Nutritional History

Special Dietary Needs

Social History and Habits

Coffee Cups/Day

Tea Cups/Day

Alcohol drinks/day/week

Tobacco cigarettes/day

How many years have you been smoking? If you quit, when did you stop?

Do you currently use marijuana YES/NO

If YES, how often and by what method, does it help alleviate symptoms of your qualifying condition?

Recreational Drug Use - Frequency/Type/Route, ie. ingestions, injection, snorting

Please download, fill out and sign the rest of the in-take form before coming in