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Age
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WHAT IS YOUR CHIEF COMPLAINT?
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May we leave messages on your cell phone?
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May we leave messages on your home phone?
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Primary Care Provider (PCP)
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PCP Address
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PCP Phone#
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PCP Fax#
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Date of Last Primary Care Visit
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Past Medical History
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If weight loss, please specify.
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If cancer, please specify
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If other, please specify.
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Past Surgical History - Include the surgery date
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Hospital
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Family History - Mother (alive or deceased)
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Age
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Medical conditions
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If other, please specify.
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Father (alive or deceased)
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Age
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Medical conditions
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If other, please specify.
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Siblings
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Age
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Medical conditions
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If other, please specify.
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Females: Are you Pregnant?
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Are you Breast Feeding?
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IF YES, PLEASE SEE RECEPTIONIST
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Do you use tobacco?
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If yes, how many per day?
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Do you drink alcohol?
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If yes, how many drinks per week?
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Do you use street drugs?(Meth, Heroin, LSD, etc)
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If yes, what street drugs do you use?
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On a scale of 1-10 what level of pain?
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Where do you have pain?
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Are you taking any supplements or herbs?
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If yes, what supplements and herbs?
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Pain Diagram
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How much/how often?
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Please Choose All That Apply
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Allergies
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Anxiety
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Amyotrophic Lateral Sclerosis (ALS)
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Attention Problems
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Asthma
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Broken/Fractured Bones
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Back Problems
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Crohn's Disease
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Cancer
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Diabetes
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Depression
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Dizziness
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Diarrhea
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Difficulty Swallowing
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Difficulty Breathing
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Earache
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Difficulty Urinating
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Glaucoma
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Facial Pain
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Heartburn
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Headache
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HIV/AIDS
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Hepatitis C
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Joint Pain
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Lupus
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Migraines
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Multiple Sclerosis (MS)
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Neck Pain
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Parkinson's Disease
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PTSD
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Shoulder Pain
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Spasms
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Other
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Wrist Pain
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If Other, Please Specify
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Symptoms (Select all that apply): General
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Cardiovascular
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Dermatology
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Psychiatric
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Neurological
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Respiratory
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Urinary
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Musculoskeletal
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Gastrointestinal
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Ears/Nose/Throat
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Hematologic
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Endocrine
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If other, please specify
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Past or Current Treatments
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Do your symptoms affect your daily activities?
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If yes, how does it affect?
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What makes your condition better?
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What makes your condition worse?
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Are you seeking medical cannabis authorization?
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Have you ever had a prior cannabis certification
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Currently use cannabis to treat any issues?
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If yes, how long have you had it?
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How do you choose to use cannabis?
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What age did you first use cannabis?
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How often are you using?
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If yes,how much cannabis are you using?
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Do you have a particular strain you like?
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Have you had any positive effects from cannabis?
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Have you had any negative effects from cannabis?
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What level of education have you completed?
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If employed, what is your occupation?
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What is your employment status?
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How much do you exercise?
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How many hours do you sleep per night?
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How much are you drinking soda?
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How much are you drinking water?
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How much are you drinking milk?
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How much are you drinking juice?
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How much are you drinking coffee?
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