Telehealth Clinical Assessment Form
Patient Information
Complete this form to let us guide you on how to buy the best product for your symptoms and how to use cannabis correctly
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Single
Married
Divorced
Widowed
Occupation
Do you smoke?
Medical Data
Complaint
Privious Diagnosis
Height (ft)
Weight (lbs)
From 1 to 10, 10 being the best, how is your overall feeling?
Breathing - How easy are you to breathe?
Follow by rating from 1 to 10, 10 being the best
Body - How easy is it for you to be still and comfortable?Spirit - How easily do you have to smile now?
Spirit - How easily do you have to smile now?
Symptom - Assess your well-being by classifying your symptom(s).
Do you have any allergies?
Food
Environmental
Medication
No allergies are known
Other
Are you taking any medications currently?
Any meds including supplements
Existing Medical Problems/Conditions
Previous hospitalization
Provide the reason and treatment
Do you suffer from
Stress
Sleep Disorter
Chronic Pain
Anxiety
Depression
Cardiovascular Problems
Other
Always check your “Internal Inventory” to check in with your body and mind before and 1 hour after use and compare the difference here.
Follow by rating from 1 to 10, 10 being the best
Assessment
System Review
Rows
Normal
Not Normal
Notes/Remarks
Sensory (Eyes, ears, nose, throat)
Musculoskeletal (Mobility)
Integumentary (Rashes, irritation, pale)
Neurovascular (Paint, seizures, sensation)
Circulatory (Skin, edema)
Respiratory (Shortness of breath)
Dental (Dentures)
Psychosocial (Hallucinations, delusions)
Nutrition (Diet, weight change, swallowing)
Elimination (Constipation, incontinence)
Additional comments
Goals of Care
Patient's Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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