PATIENT RENEWAL

PATIENT RENEWAL
Name as it appear on Health Card:*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Are you Veteran?*

YesNo
K#:
Will you applying to Health for your ACMPR license ("grow license").*

YesNo
Will you be using a 'Designated Grower'?

YesNo

	Yes
Abdominal Pain
Anxiety
Back Pain
Chronic Pain
Constipation
Depression
Diarrhea
Difficulty Eating
Muscle Spasms
Nausea
Neck Pain
Seizures

	Yes
Difficulty Sleeping
Fatigue
Foot Pain
Headaches
Hip Pain
Low Energy
Menstrual Pain
Mobility Issues
Shaking
Vision Issues
Weakness
Weight Loss

Patient Intake
Current Grams Per Day*
Would you like to increase your grams per day? Will you be using a 'Designated Grower'?

YesNo
What is your reasoning?
What would you like to request for your NEW grams per day?
Current Licensed Producer(s):
If you would like to switch license producer(s), please indicate new licensed Producer request(S) here:
Why would you like to switch Licensed Producers?
Medical condition(s) being treated by cannabis:

CANNABIS CONSUMPTION
What is your preferred method of cannabis consumption?
Have you experienced any 'adverse reaction' to cannabis?

YesNo
Please explain the adverse reaction:
Please list any medication you are taking:

Info from home medication list as identified from intake history, patient, family, prescription bottle
Drug Names:

	Dose	Frequency	Administration Route
1
2
3
4
5
6

Allergies
Is there anything the health care practitioner should know? If so please list it:

Brief Pain Inventory

This is only for physical pain. You do not have to answer these questions if you do not have physical pain.
1. Pain from time to time occurs (for example headaches, toothaches, sprains, etc). Have you experienced everyday pain not related to these common everyday pains?*

YesNo
2a Please indicate on the diagrams the areas affect by pain:
2b. Please indicate on the diagrams the areas affect by pain:
3. Please rate your pain by associating it to a number below that best describes the pain at its worst in the last 24hrs. (0 to be minimum, 10 to be maximum)*
4. Please rate your pain by associating it to a number below that best describes the pain at its best in the last 24hrs. (0 to be minimum, 10 to be maximum)*
5. Please rate your pain by associating it to a number below that best describes the pain on average. (0 to be minimum, 10 to be maximum)*
6. Please rate your pain by associating it to a number below that best describes the pain you're experiencing right now. (0 to be minimum, 10 to be maximum)*
8. Please rate how your pain affects the following in the 24hrs. (0 to be minimum, 10 to be maximum)
a) General activity*
b) Mood*
c) Walking ability*
d) Normal work (outside/home/housework/etc.)*
e) Relationship with other people*
f) Sleep*
g) Enjoyment of Life*
h) Ability to concentrate*
I) Appetite*
9. In the area where you experience pain, do you have the sensation of 'pins and needle', tingling, prickling or any similar sensation?*

YesNo
10. Does the area you experience pain change in color (mottled, redness, etc.) when the pain is bad?*

YesNo

Patient Consent to Disclose Information
First Name* Last Name* , hereby acknowledge that all the information provided by me is truthful and does not contain any information that might mislead the process.
Please upload Photo ID and other supporting documents.

Cancelof
Acknowledgement*

Clear
Should be Empty:

	Not at all	Several Days	Over half the days	Nearly everyday
1) Little interest or pleasure in doing things.
2) Feeling down, depressed, or hopeless
3) Trouble falling or staying asleep, or sleeping too much
4) Feeling tired or having little energy
5) Poor appetite or overeating
6) Feeling bad about yourself—or that you are a failure or have let yourself or your family down
7) Trouble concentrating on things, such as reading the newspaper or watching television
8) Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9) Thoughts that you would be better off dead or of hurting yourself in some way

	Not at all	Several Days	Over half the days	Nearly everyday
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

PATIENT RENEWAL

PATIENT ASSESSMENT

What symptoms apply to your current medical condition(s)?

Patient Intake

CANNABIS CONSUMPTION

Please list any medication you are taking:

Brief Pain Inventory

8. Please rate how your pain affects the following in the 24hrs. (0 to be minimum, 10 to be maximum)

Patient Health Questionnaire (PHQ-9)

Generalized Anxiety Disorder 7-item (GAD-7) scale

Patient Consent to Disclose Information