Medical Marijuana Intake Form

AFFIRM DIRECT PRIMARY CARE
Please complete the documents below

Medical Marijuana Intake Form- Bennett

Medical Marijuana Consent- Bennett
Medical Marijuana Intake Form
Please enter your information.
Full Legal Name*

First NameLast Name
Date of Birth (M/D/YYYY)*

MonthDayYear
Date
Street Address*
City*
State*
Zip Code*
Current Weight (lbs)*
Mobile Phone*
Email*

Confirmation Emailexample@example.com
Are you a permanent Florida resident?*

YESNO
Patient Status*

New Marijuana PatientExisting Marijuana Patient
How did you learn about Affirm DPC?

GoogleFacebookDispensaryOther
Who referred you?*
New Medical Marijuana Patients
The next two questions are for New Patients in the Medical Marijuana Program (NEW PATIENTS ONLY)
Social Security Number *. *Option to provide during consultation
FL Drivers License (MUST BE VALID) *
**This information enables us to create your account on the Florida State Medical Marijuana Use Registry.
Existing patients in the Medical Marijuana Use Registry
Patient ID Number*
Card Expiration Date*

MonthDayYear
Date
Certification Expiration Date*

MonthDayYear
Date
What products have you tried, please note effectiveness*
What brings you in today?
What is the main reason for the consultation? What issues would you like to focus on?*
How long have you had the conditions about which you are consulting us?*

Less than 6 months6 months to 2 years2 to 5 yearsMore than 5 years
Have your health problems progressed since they began?*

StableRapidly improvingGradually improvingGradually worseningGradually improvingFluctuatingRapidly Worsening
How often are you having pain or discomfort?*

Less than once per weekSeveral times per weekOnce a daySeveral times per dayMost of the time
Do you take any prescription medications, over-the-counter medications, vitamins or any other supplement(s)?*

YesNo
Please list them*
Are you currently under the care of a family physician or any other health*

YesNo

Health

Please Fill Out

	Myself	Child	Mother	Father	Grandparents
Alzheimer's Disease
Anemia
Cancer
Chronic Mood Disorder (Anxiety, Depression, Panic Disorder, etc.)
Eating Disorder (Anorexia Bulimia, etc.)
Epilepsy
Diabetes
Glaucoma
Heart Disease
High Blood Pressure
Mental Illness
Rheumatoid Arthritis
Stroke
Autoimmune Disease
Psoriasis/ Psoriasis Arthritis

If Cancer/Mental Illness, please specify type:
Do you smoke? (cigarettes or other substances)*

YesNoPastNever
Date Quit*

MonthDayYear
Date
Packs a Day*
Years*
Drink Alcohol? (cigarettes or other substances)*

YesNoPastNever
Date Quit*

MonthDayYear
Date
Have you ever felt the need to cut down on your drinking?*

YesNo
Currently Use Marijuana?*

YesNoPastNever
What Form?*

Whole Flower Inhalation (Vape)EdiblesTopicalOral Sublingual
Have Allergies?*

YesNoUnknown
What Substance?*

FoodPollenDustOther
How regularly do you follow your ideal routine? (e.g.: go to bed early, eat meals on time, exercise regularly)*

Very RegularlySomewhat RegularlyIrregularly

How would you describe your sleep experience?*

	Sound, normal duration	Not enough	Difficulty falling asleep	Light, interrupted	Too heavy and/or long	Difficulty waking up	Awaken too early
Check all that apply

Are you postmenopausal?*

YesNo
Are you currently pregnant or could be pregnant?*

YesNoUnknown
Do you take contraceptive pills or use other forms of birth control?*

YesNo
Please Specify*
Do you have any past medical history or problems (illness, trauma, emotional stress, addictions, drug abuse) or anything not mentioned that will help us clearly understand your health condition and provide the most helpful guidance)?
Did you experience any abuse or trauma as a child?

EmotionalVerbalPhysicalSexualOther
Please sign I hereby authorize Affirm DPC Practitioner and/or such assistants as may be requested by said physician to review the above-noted medical information provided. I acknowledge that no warranty or guarantee has been made as to the results of this appointment. I understand that any aspect of this consent form that I do not understand can and will be explained to me in further detail by asking the physician.
Signature*

Clear
Should be Empty:

	Health Professional Name	Health Professional Contact	Condition	Treatment
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AFFIRM DIRECT PRIMARY CARE

Medical Marijuana Intake Form

New Medical Marijuana Patients

What brings you in today?

Health