2021 UTTHC Clinic Form

Today's Date

YearMonthDay
Date
Card Expiration Date Future (new patients)

YearMonthDay
Date
Visit1 Date Seen

YearMonthDay
Date
Visit3 Date Seen

YearMonthDay
6-month renewal
Visit4 Date Seen

YearMonthDay
1-year renewal
What would you like to do?*
Show All Chart Sections

Yes
Patient Name*

First NameLast Name
E-mail*
Provider Seeing the Patient Today (Rendering Provider)*
Rendering Provider is the Provider doing the work today. QMP is the provider registering the patient with the EVS.
Change QMP?
QMP*
Rendering Provider is the Provider doing the work today. QMP is the provider registering the patient with the EVS.
Clinic Location*
Clinic Location Renewal*
ID Verified

YesNo

Allergies (click to expand)
Common Medication Allergies

PenicillinSulfa / bactrimIbuprofenNo known allergies
Other Allergies

Type a question

HISTORY / MDM (required)
General history of the condition.*
More detail is required below.
Reviewed Medical Records?
Qualifier*
The following line is for PTSD patients. QMPs must provide the first name and what provider the patient is being treated by. This is only for PTSD patients.
Treating Provider
PTSD Attestation
Specific Diagnosis
Patient on Hospice?

YesNo
Expected Survival
Currently using cannabis?
Level of experience.
MDM - Provider Notes
MDM - Provider Notes Renewal

Cannabis Recommendation and Education
Delivery*
Restricted Forms / Dosing Notes
Dosing / Purchasing Limits ordered or requested*
Benefits vs Risks. *
The condition suffered by this patient is both severe enough to seek medical evaluation and treatment and severe enough to negatively affect the patient's daily routine. So far the condition is not well controlled with traditional therapy and although prescription medications may help and may have helped in the past, cannabis may be a safer alternative and in the patient's interest as a treatment alternative. I therefore recommend that the patient be able to utilize cannabis as a treatment for their symptoms. State basis for why you believe that the potential benefits of medical cannabis treatment outweigh the risks.
After a full review of the patient's condition, I recommend this patient be allowed to use cannabis under the Utah Cannabis Act.*
After a full review of the patient's condition, I recommend this patient be allowed to continue to use cannabis under the Utah Cannabis Act.*
Has the patient, parents, guardians, and caregivers been informed of the risks of cannabis use?

YesNoOther
Was the Controlled Substance Database checked for relevant medication history?

YesNoOther
This Patient's ID was NOT VERIFIED. Put this chart in "Cleanup"
I instructed the patient to lock medications in a locked cupboard or in a tamper-proof storage container and keep the keys/combinations away from children.
Should be Empty: