MICHIGAN - MEDICAL FORM
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Name
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First Name
Last Name
State
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MIchigan
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Date of Birth
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Gender
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Address
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Email
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Are you taking any medications?
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What medication are you currently taking?
Have you ever been diagnosed with Schizophrenia?
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Have you ever experienced Hallucinations before?
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What is your medical history like?
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Amyotrophic lateral sclerosis.
Anxiety disorders.
Autism.
Cancer, including remission therapy.
Crohn’s disease.
Damage to the nervous tissue of the central nervous system (brain-spinal cord) with objective neurological indication of intractable spasticity, and other associated neuropathies.
Dyskinetic and spastic movement disorders.
Epilepsy.
Glaucoma.
HIV / AIDS.
Huntington’s disease.
Inflammatory bowel disease.
Intractable seizures.
Multiple sclerosis.
Neurodegenerative diseases.
Neuropathies.
Opioid use disorder for which conventional therapeutic interventions are contraindicated or ineffective, or for which adjunctive therapy is indicated in combination with primary therapeutic interventions.
Parkinson’s disease.
Post-traumatic stress disorder.
Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain.
Sickle cell anemia.
Terminal illness.
Tourette syndrome.
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Provide some basic medical history and book an appointment with a licensed marijuana doctor. The $169 fee includes your consultation fee, physician copay, and the medical evaluation for your recommendation.
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