Download Print Patient Intake Form

Patient Intake Form
Put something on every line
This recommendation (circle one) New – Renewal
First Name:______________________________
Last Name:________________________________
Date of Birth:________________________ Age:______
Sex: M F
Address: ____________________________ City:_____________________ St: _____ Zip______
Home Phone________________ Cell:____________________ Email:_____________________
Referred by:___________________________________________________________________
Your Medical Information – Important (YES or NO)
Health Habits: Alcohol:______________________ Tobacco:_______________________
If female, pregnant? Yes No
Family Medical Problems:_________________________________________________________
Surgeries / Broken bones:_________________________________________________________
Medications taking now (prescription or over the counter):______________________________
______________________________________________________________________________
Medications Allergies or side Effects:________________________________________________
(side effects can be why you wishmedical cannabis instead of pills)
The ‘Last’ Medical Doctor or Clinic Visit: (in the last 10 years)
Name:________________________________________Phone:_____________Fax______________
Address, City,State:_________________________________________________________________
Date AND reason of last visit:__________________________________________________________
Date AND reason of next planned visit:__________________________________________________
If no doctor listed above, reason why!___________________________________________________
Have Medical Insurance now? (please circle) Yes No Name:______________________________
Patient Initials:________
Medical Symptoms / Diagnosis – Reason(s) for today’s evaluation
I________________, came to see the doctor because I request a recommendation for the medicinal use of marijuana because I
believe that the medicinal use of marijuana use of marijuana will relieve my symptoms (i.e., health problems). I have the
following symptoms and/or diagnosis:
(check and/or circle times below)
x
x
Symptoms
Anxiety / Stress
Depressed feelings
Headaches
Insomnia / Sleeping disorder
Pain, Neck or Back
Pain, Joints, where:
Muscle spasms, where:
Numbness or tingling in limbs
Other:
Diagnosis made by a doctor
AIDS / HIV
ADHD (attention deficit hyperactivity
disorder)
Bipolar
Depression diagnosed
Schizophrenia
Glaucoma
Heart disease
High Blood Pressure
Stroke
Migraine Headaches
Stomach Ulcers
Other:
x
x
Symptoms
Acid Reflux / Heartburn / Stomach Pain
Loss of appetite / Weigh to gain
Nausea / Vomiting
Constipation (especially with medications)
Chronic Cough
Dizziness / Vision problems
Urinary problems
Other:
Other:
Diagnosis made by a doctor
Arthritis of:
Asthma
Cancer of:
Diabetes w/ extremity pain or nausea?
Disabled permanently:
Epilepsy / Seisurez
Hepatitis: B C
Kidney disease
Multiple Sclerosis / CP
Muscle or Movement Disease
Parkinson’s Disease
Other:
For your most significant problem listed above:
(try and put something on every line here – important)
1.Main Problem:_______________________________________________________________________
2.What caused your problem:_____________________________________________________________
3.How long have you had these symptoms:__________________________________________________
4.Frequency of symptoms:_______________________________________________________________
5.Intensity of symptoms:_________________________________________________________________
6.All treatments for this problem:__________________________________________________________
7.More details:_________________________________________________________________________
8.Have x-rays, test results?_______________________________________________________________
9.Additional doctors seen for this problem: (name, address, date of visit, reason of visit)
Patient Initials_______
Patients Statement Regarding:
Primary Diagnosis and Medical Records
Did you see a doctor OR clinic, for your medical symptoms / problems?
Please write YES or NO here:_________________
1. If you answered YES, then can you provide this office with a copy of your medical records, x-rays, and
prescriptions ? _________
2. If you answered YES, but CANNOT provide us with the medical record copies, then please provide the following
information:
a) I cannot provide the records because of:_________________________________
b) What medical conditions were you being treated for: (list all and be specific)
________________________________________________________________________
c) Was a specific DIAGNOSIS made by the doctor? Write YES or NO:_____________
If YES, what was the diagnosis:_________________________________________
On what DATE was the diagnosis made? _________________________________
d)
Was this the same doctor or clinic you listed on page 1? Yes No
If NO, then write the doctor/clinic, address, city, state, who treated your problem :
______________________________________________________________
Your personal statement regarding the above facts:
I, (print name)___________________________, confirm that the information provided by me regarding my diagnosis
and medical records, is true and correct.
_____________________________________ ________________
Signature
Date
Disclosures and Conditions
Based on my belief and general information that I have obtained from different sources, which includes researching scientific literature
about the established benefits and risks of using cannabis to treat my medical problems. I request the doctor to EVALUATE me for a
possible recommendation for medicinal use of marijuana which would enable me to legally obtain cannabis.
Patients Initials:________
I have been notified by this office and agree that if the use of cannabis ADVERSLY affects my health, I will st op using cannabis and will
schedule an appointment to be further evaluated by a physician to determine another form of treatment for relief of my health problems. I
assume all risks for usage.
Patient initials:________
Disclosures and Conditions – Cont.
I agree to provide the physician with any and all copies of my MEDICAL RECORDS, if they exist, that document my medical
conditions, as requested by the physician.
THIS IS VERY IMPORTANT – Patients Initials:______
I agree to obtain medical FOLLOW-UP at my personal medical doctor’s office, or obtain a personal doctor if I have none now, and
to return to this office for FOLLOW-UP, as recommended by the physician. I understand this is an obligation on MY part for the
continuity of care.
THIS IS VERY IMPORTANT – Patient Initials______
I understand that SIDE EFFECTS associated with medical marijuana use include: dry mouth, nausea, headache, tremor,
nystagmus, rapid heart rate, reduced muscle strength, decreased brain blood flow, decreased coordination, lung irritation,
increased weigh gain, altered body temperature, anxiety, paranoia, confusion, aggressiveness, hallucinations, suicidal thoughts,
sedation, altered libido, altered perceptions, addictive behavior, reduced testicular size and testosterone, menstrual
abnormalities, infertility, abnormal ova, feta exposure in pregnancy.
Patient Initials:______
I agree NOT TO DRIVE a car or operate dangerous or heavy machinery while using marijuana.
Patient Initials:______

I DO NOT plan or intend to use my physician’s recommendations for the purpose of illegally obtaining medical cannabis.

I AM NOT CURRENTLY ON PROBATION OR PAROLE. I UNDERSTAND THAT IF I AM ON PROBATION OR PAROLE AND
DO NOT DISCLOSE TO THE DOCTOR, THEN MY RECOMMENDATION MAY BE REVOKED AT ANY TIME. I ALSO
UNDERSTAND THAT WHILE ON PROBATION / PAROLE, ALL STATE AND FEDERAL LAWS SUPERSEDES MY MEDICAL
RECOMMENDATION. IF MARIJUANA POSSESSION OR USAGE VIOLATES CONDITIONS OF PAROLE / PROBATION, THEN
MY RECOMMENDATION MAY BE REVOKED AT ANY TIME.

I understand that I must be a California State resident to obtain an approval or recommendation for the use of cannabis
(i.e., medical marijuana)under California’s Compassionate Use Act of 1996 (Health & Safety Code #11362.5)

I affirm that I have a serious medical condition that adversely affects my quality of life.

I have found or am interested in determine whether cannabis (i.e., Medical Marijuana) provides substantial relief and
improvement of my condition.

I have discussed and have been informed by the medical practitioner of the potential benefits and risks of using
cannabis.

I have been assured that medical records relating to my care will be kept private and confidential and that no
information will be released or printed, which would disclose my personal identity, unless required by law.

I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations (FDA) concerning the
safety and effectiveness of the medical use of marijuana as a drug, I understand the significance of this fact.

California’s compassionate use act of 1996, (Health and Safety Code #11362.5) provides for the possession and
cultivation of cannabis (medical marijuana) for the personal medical absolutely clear the physician, staff and
representatives of this practice are neither providing cannabis, nor are they encouraging any illegal activity in my
obtaining or using cannabis (medical marijuana).
I have read, understand, and affirm all the above statements – Patient Initials:______
I understand that my recommendation must be renewed either on, or before the
expiration date in order to be considered a renewal patient next year.
This is very important – Patient signature ______________________________
Disclosures and Conditions – Cont.

Furthermore, the undersigned, my heirs, assigns, or anyone acting on my behalf, hold the physician, the
principals, agents and employees, free and harmless of any liability resulting from the use of cannabis.

There are no claims about the medical efficacy of cannabis.

This clinic, its staff and representatives are addressing specific aspects of my medical care, and unless
otherwise stated are in no way establishing themselves as primary care provider.

Should an approval be made for my medicinal use of cannabis, I understand that term and renewal date
will be specified. I understand that this is my responsibility to see a physician to assess the possible
continuance of cannabis use beyond the term of approval.

I understand that the benefits and risks associated with the use of marijuana are not fully understood and
that the use of marijuana may involve risks that have not been identified.

I AM NOT CURRENTLY IN A CHILD CUSTODY OR OTHER MEDICAL / DISABILITY DISPUTE. I CLEARLY
UNDERSTAND THAT MARIJUANA USAGE UNDER THESE SITUATIONS IS NOT RECOMMENDED BY OUR
OFFICE UNTIL AFTER DISPUTE RESOLUTION.

THE EVALUATION THAT I RECEIVE TODAY IS NOT TO BE UTILIZED IN ANY MANNER FOR SUPPORT OF A
DISABILITY CLAIM, WORKMEN’S COMPENSATION CLAIM, OR LIFE / DISABILITY/OR OTHER INSURANCE
APPLICATION. I WILL CONSULT A DEDICATED DOCTOR FOR THIS IF I AM IN NEED.

I AM NOT CURRENTLY IN ANY DRUG OR ALCOHOL REHAB PROGRAM

I am not a student in high school

I CLEARLY UNDERSTAND THAT NEITHER THE OFFICE NOT THE DOCTOR CONDONES ANY ILLEGAL
ACTIVITY WITH REGARDS TO MEDICAL MARIJUANA USAGE. ANY IMPROPER USE WILL LEAD TO THE
REVOKATION OF MY MEDICAL RECOMMENDATION.
I certify that I have carefully read all the DISCLOSURES and CONDITIONS above with full understanding and
agreement.
I certify that all information I have provided in this ‘patient intake form’ is true and correct.
I certify that all information verbally transmitted to the doctor is true and correct.
I am seeking a recommendation for my own, personal, medical use.
____________________________________
Signature
___________________________
Date