Health History Questionnaire
Please be as honest as possible.
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Age
Marital Status
Single
Married
Separated
Divorced
Widowed
Gender
Male
Female
Social / Work History
Current Occupation Status
Employed
Unemployed
LOA
Other
Occupation or Last Occupation
Please describe the way you want your event to be.
Are you taking any medications?
Yes
No
List your medications
Only Answer for yourself
Type
Current
Past
Comment
Alcoholism/Drug Abuse
Asthma
Cancer
Depression/Anxiety/Bipolar/Suicidal
Diabetes
Emphysema (COPD)
Heart Disease
High Blood Pressure (hypertension)
High Cholesterol
Hypothyroidism/Thyroid Disease
Renal (kidney) Disease
Migraine Headaches
Stroke
Other:
Other:
Please indicate the major surgeries that you had (if any)
Female Health History
Details
Date of Last Menstrual Cycle:
Age of First Menstruation:
Age of Menopause:
Total Number of Pregnancies:
Number of Live Births:
Pregnancy Complications:
Family Medical History
Mother
Father
Child
Maternal GM
Maternal GF
Paternal GM
Paternal GF
Alcohol/Drug Abuse
Asthma
Emphysema (COPD)
Depression / Anxiety
Bipolar / Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Please Indicate which among your direct relatives has or had cancer
Do you smoke on a regular?
Yes
No
How many times per day
How long have you been smoking?
Do you use any other recreational drugs?
Yes
No
Do you drink alcohol?
Yes
No
Review of Current Systems
Constitution
Activity change
Appetite change
Chills
Diaphoresis
Fatigue
Fever
Unexpected weight change
Eyes
Blurry vision/Double vision
Cataracts/ Macular degeneration
Glasses/Contacts/Blindness
Glaucoma/Retinopathy
Partial loss of vision/blind spots
Ears/Nose/Mouth/Throat
Dentures/Difficulty swallowing
Hearing Loss/ringing in ears
Prolonged Nose bleeds
Voice change
Cardiovascular
Ankle Swelling /Varicosities
Calf pain with/without exercise
Chest pain with exertion/Exercise
Chest pain/ Heart murmur
Dyspnea on exertion/Syncope
Irregular/Rapid heart rate
Leg Pain/Cramping in legs at night
Respiratory
Asthma/ Anesthetic problems
COPD/Pneumonia/Emphysema
Coughing/coughing up blood
Hoarsness/Obstructive Sleep Apnea
Oxygen Dependent LPM
Shortness of Breath with Exertion
Shortness of breath /Wheezing
Tuberculosis or exposure
Gastrointestinal
Abdominal pain/Blood in stool
Black or Tarry stool
Bloating/Diarrhea/Constipation
Loss of appetite/Heartburn
Nausea/Vomiting
Ulcer disease/Pain after eating
Vomited blood
Endocrine
Cold/Heat intolerance
History of drug resistant infection
Integumentary (Skin)
New skin lesions/Skin Cancer
Rash/Persistent itching
Unhealed/Delayed healing of sores
Neurological
Migraines/Headache/Vertigo
Temporary/Paralysis Arm/Leg/Face
Tingling/Numbness
Speech difficulties/Seizures
Musculoskeletal
Artificial knee or hip joint
Back pain/Joint pain
Degenerative/Osteoarthritis
Muscle pain/Weakness/Cramps
Rheumatoid Arthritis
Genitourinary
Impotence
Incontinence /Difficulty Voiding
Kidney stones
Suprapubic/Indwelling Catheter
Urgency/Blood in Urine
Psychiatric
Anxiety/Depression
Confusion/Memory loss
Difficulty sleeping
Heme/Lymphatic/Immune
Anemia/Low platelet count
Bleeding disorder/Easy bleeding
Easy bruising
Lymphoma/Leukemia
Frequent illnesses
Do you want a consultation to go over how Cannabis can help your medical issues.
Yes
No
Back
Next
THC and CBD Usage
Why do you use THC
Health Benefits
Recreation
Social
Other
What Type of THC do you prefer?
Indica
Stativa
Hybrid
I have no clue what those are.
How many hours a day are you stoned?
Less than 1
2 to 5
6 to 9
10 or more
How do you want to feel when you leave the party
Energetic and Uplifting
Calming, Sedating, Relaxing
Somewhere in the middle
Not sure
Do you have any allergies?
Yes
No
Please list any allergies
Please list any and all foods that you WILL NOT eat.
Do you have a favorite meal in mind for this experience?
What type of atmosphere do you want for your event?
Casual
Fine Dinning
Munchie
Family Style
Please Upload 2 Forms of ID to Verify Proof of Age.
Browse Files
Drag and drop files here
Choose a file
Driver's License, State ID, Passport, Medical Marijuana Card
Cancel
of
How many people will be attending your event?
Any questions, comments, or Concerns?
Submit
Should be Empty: