Patient In-Take Form Download full intake form Download PDF 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 TreatmentChief 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 Fill Out The Rest Here