Patient Intake Questionnaire Filling out this form does not guarantee an approval or recommendation for the use of medicinal cannabis. Step 1 of 4 25% Name* First Middle Last Date* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* This will be the email where we send your digital card.Phone*This will be the number our doctor uses to contact you.Driver License/State ID Card # or Passport #*Are you a new or returning patient?*NewReturningDate of Birth* Date Format: MM slash DD slash YYYY Age*WeightHeightOccupation Current Chief Medical Complaint:*Please describe the medical condition or complaint that you are seeking a recommendation for medical marijuana.Are you currently under the care of a physician?YesNoThis field is not required.What is the name of your primary care physician?This field is not required.Physician's AddressThis field is not required.Physician's PhoneThis field is not required.Did you bring medical records/documentation today?YesNoThis field is not required.If yes, please upload your documents. Drop files here or Accepted file types: pdf. Please upload your documents in PDF format. Alternatively, you can mail them to us.Have you been evaluated for the use of medical marijuana by any other physician in the past?YesNoIf yes, please give name of doctor, date seen and condition for which cannabis was approved.Have you been evaluated and denied a medical marijuana recommendation?YesNoIf yes, please explain:Female PatientsAre you currently pregnant?YesNoAre you planning a pregnancy?YesNo Have you ever been treated for symptoms of depression, been psychotic, attempted suicide or had any other mental problems?YesNoIf yes, explain:Have you ever been prescribed or taken medication for any of these problems?YesNoIf yes, what medications:If applicable, what is the name of your mental health physician:Do you currently smoke tobacco?YesNoIf yes, how often and how many per day?Do you currently use marijuana?YesNoIf yes, how much do you use per week?What method(s) do you currently use to consume the cannabis? Vaporize Ingest Smoke Anointing Oil Other If you selected Other above, explain:Are you taking any medications?YesNoIf yes, name the medication(s) and dosages below:Do you have any allergies to medicine?YesNoIf yes, please list medicine:Have you had hospitalizations related to why you use or want to use medical marijuana?YesNoIf yes, give dates and details:Have you ever had surgeries/operations that pertain to the reason why you are seeking medical marijuana?YesNoIf yes, give dates and details:Please indicate any other significant medical problems you have:* Asthma Stroke High Blood Pressure Tuberculosis Diabetes Alcoholism Hepatitis Cancer Substance Abuse Kidney Disease Heart Disease Sinusitis None of the above Please indicate if you have had any of the following symptoms consistently: Sleeplessness Stomach Pain Skin Rashes Coughing Chest Pain Depression Palpitations Heart Burn Constipation Vomiting Headaches Seizures Nausea Anxiety Chronic Pain Eye Problems Diarrhea Rectal Pain Fever Blood in the Bowels Loss of Appetite Swollen Ankles Muscle Spasms Difficulty Swallowing None of the above Describe any other health problems that occur frequently with you or in your family Please read each item below and initial in the space provided to indicate that you understand the information regarding the risks and side effects of using cannabis. I agree to tell the attending physician if I do not understand any of the information provided.I understand that the cultivation, possession and use of cannabis, even for medical purposes, are currently illegal under federal law.*I understand that the attending physician, including the physician’s employees, may not provide information regarding where the medicinal cannabis might be obtained. Doing so would be a violation of federal law.*The efficacy and potency of cannabis varies widely depending on the cannabis strain and method of use (inhale, ingest or tincture). Under California law, the doctor may provide a treatment plan.*Symptoms of a cannabis overdose include, but are not limited to, nausea, vomiting, numbness, irregular heartbeat, drowsiness, and anxiety.*In the event of an overdose, I am advised to lie down, relax, and rest. If the symptoms persist, I agree to contact the attending physician.*Cannabis smoke contains tars and may include carcinogens (chemicals that can cause cancer) that have potentially harmful effects including increasing the risk of respiratory diseases and cancer of the lungs, mouth, and tongue.*There is little known regarding how cannabis may, or may not, react with other pharmaceutical or herbal medications.*Use of cannabis may result in higher and higher dosages due to user’s development of a tolerance to cannabis.*I understand that the use of cannabis may affect my coordination and cognition. I agree not to operate heavy machinery, drive or engage in potentially hazardous activities while using cannabis.*I understand that it is against the law to drive a vehicle while using marijuana and that I can get a DUI for driving under the influence.*The use of a vaporizer, as an ingestion method, can substantially reduce the potentially harmful effects of smoking cannabis.*Cannabis may be ingested in a tincture of edible form that eliminates some of the potentially harmful effects of smoking.*I understand that any of the following side effects can result from the use of cannabis:* Short term memory loss Anxiety/Nervousness Irregular heart beat Dry mouth Slower reaction time Poor physical coordination Hunger Loss of appetite Dizziness Cough Dependency Confusion Impaired vision Feeling of euphoria Drowsiness Headache Nausea/Vomiting Tiredness Apathy Depression Changes in sleep patterns Numbness Laryngitis Bronchitis Shortness of breath Agitation/irritability Trouble concentrating Low blood pressure Sedation Difficulty completing complex tasks Inability to concentrate Paranoia, psychotic symptoms (i.e., delusions) Suppression of immune system Talkativeness Impairment of motor skills, coordination, and reaction time I understand that there may be benefits and risks associated with the use that have not been identified.*I agree to stop using cannabis and inform the attending physician in the event that I experience depression, have thoughts of suicide, or any other mental problems.*I also agree to inform the attending physician of any anti-psychotic medication that I may be taking currently or in the future.*There is a possibility that cannabis may worsen schizophrenia in persons predisposed to that disorder.*I agree to stop using cannabis and inform the attending physician if I am experiencing any negative side effects that may be caused from my therapeutic use of cannabis.*There is the possibility of experiencing withdrawal symptoms when I stop using cannabis. I understand that these withdrawal symptoms can include, but are not limited to, depression, irritability, insomnia, loss of appetite, and tiredness.*I understand that cannabis is not recommend while under the influence of alcohol.*I hereby state that I fully understand the potential risks and side effects related to the use of cannabis as described above.*Furthermore, in using cannabis therapeutically, I accept full responsibility in assuming the risks and side effects related to its use.*I agree that the attending physician and his/her principals, agents, and employees, shall not be held responsible for any harm resulting to me and/or other individuals as a result of my medicinal use of cannabis.**I hereby declare that I am 18 years of age or older, I have completely and truthfully disclosed all information regarding my medical condition and attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal for a patient to film or record in this office with video camera, cell phone or any other recording device whether still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor confidentiality. I am aware that my approval or recommendation may be revoked at any time if I have perjured or misrepresented myself or my condition. I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECTApplication Fee* Price: $39.00 Payment Information Card Number Expiry (MM/YY) Card Code Card Postal Code Your payment will be processed safely and securely via Square. CommentsThis field is for validation purposes and should be left unchanged.