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Patient Information
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First Name:
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Last Name:
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Address:
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City:
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State:
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Zip:
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Date of Birth:
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Phone Number:
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Email Address:
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Patient Assessment
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Cancer
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Anorexia
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AIDS
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Chronic Pain
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Spasticity
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Glaucoma
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Arthritis
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Migraine
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Other:
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Patient History
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History of Present Illness:
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Past Medical History:
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History of Substance and or Alcohol Use/Abuse:
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CURES Report Findings:
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Mental Health History:
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Current Disability Status:
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Family History (Including Substance Abuse/Addiction):
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Physical Examination:
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Prior Therapies With Inadequate Response:
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Other Treatments Available and Risk/Benefit Assessment:
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Treatment Plan
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Cannabis Treatment Recommendation:
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Recommendation Time Period (not to exceed one year):
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Additional Diagnostics and TreatmentsL
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Frequency of Assessments:
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Treatment Goals:
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Circumstances in Which Cannabis Will Be Discontinued:
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Exit Strategy:
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