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?*
- New
- Returning
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Weight
Height
Occupation

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?
- Yes
- No
This field is not required.
What is the name of your primary care physician?
This field is not required.
Physician's Address
This field is not required.
Physician's Phone
This field is not required.
Did you bring medical records/documentation today?
- Yes
- No
This 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?
- Yes
- No
If 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?
- Yes
- No
If yes, please explain:
Female Patients
Are you currently pregnant?
- Yes
- No
Are you planning a pregnancy?
- Yes
- No

Have you ever been treated for symptoms of depression, been psychotic, attempted suicide or had any other mental problems?
- Yes
- No
If yes, explain:
Have you ever been prescribed or taken medication for any of these problems?
- Yes
- No
If yes, what medications:
If applicable, what is the name of your mental health physician:
Do you currently smoke tobacco?
- Yes
- No
If yes, how often and how many per day?
Do you currently use marijuana?
- Yes
- No
If 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?
- Yes
- No
If yes, name the medication(s) and dosages below:
Do you have any allergies to medicine?
- Yes
- No
If yes, please list medicine:
Have you had hospitalizations related to why you use or want to use medical marijuana?
- Yes
- No
If yes, give dates and details:
Have you ever had surgeries/operations that pertain to the reason why you are seeking medical marijuana?
- Yes
- No
If 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 CORRECT
Application Fee*
Price: $39.00
Credit Card*

Card Details

Cardholder Name
Name
This field is for validation purposes and should be left unchanged.

Scroll to Top

Step 1 of 4

Female Patients