FL-MMJ-DR

Name:

Date of Birth:

DL#:

Gender:

MaleFemale

Phone Number:

Email:

example@example.com

SS#:

Address:

Street Address

CityState / Province

Postal / Zip Code

How did you hear about us?

Weight:

For what conditions do you seek medical cannabis?

Please list all doctors, including their name, address, phone and fax numbers that you have seen in the last five years for any condition related to your current health and your request for medical cannabis:

	Doctor Name	Address	Phone/Fax Number	Reason for visit
1
2
3
4
5
6

Past Medical History (Please mark all that apply):

	Please Mark
AIDS
IBS
Anorexia
ALS
HIV
Bulimia
Alzheimer's Disease
Auto-immune Disorder
Brain Disorders
Intestinal Disorder
Blood Disorders
Prostate Disease
Ulcers
Disc Injury
Hearing Loss
Colitis
Osteoporosis
Tinnitus
Crohn's Disease
Scoliosis
Epilepsy/Seizures/Spasms
Cachexia/Wasting Syndrome
Sciatica
Diabetes

Occupation:

Do you live alone:

Do you smoke cigarettes: blanks No blank Yes
If so, how many packs a day? blanks

Do you drink alcohol? blanks No blank Yes
If so, how many drinks per week? blanks

Are you currently pregnant or planning on becoming pregnant? blanks No blank Yes
If so, THC is contraindicated for pregnant women and nursing mothers

Past Medical History – Continued

	Tick Mark	Specify
Weight Loss/Gain (Ibs) reason.
Heart Disease
Chronic Pain
Circulation problems (stroke, phlebitis, etc.)
Fibromyalgia
Lung Disease
Migraine
Asthma
PTSD
Shortness of Breath
Anxiety
Depression
Cancer
Bipolar
Breast Lesions
Schizophrenia
Liver Disease
Kidney/Bladder disease
Hepatitis A/B/C
Insomnia
Glaucoma/Vision Problems
Sleep Apnea
MS/ALS
Endocrine Problems
Parkinson's Disease
Rheumatic Disease
Distonia
COPD

Surgical History: Please indicate if you have undergone any surgeries and provide the dates of each surgery: _________ None.

	Date of Surgery	Type of Surgery or Condition
1
2
3
4
5
6

Please provide details of any non-surgical treatments you have undergone or are currently undergoing for the condition(s) for which you are seeking medical cannabis:

	Please Mark	Specify
Physical Therapy
Pain Specialist
Orthopedist
Oncologist
Injections
Psychologist
Heart Specialist
Endocrinologist
Chiropractor
Social Worker
Neurologist
Acupuncture
Psychiatrist
Other

Assessment of Activities of Daily Living: Please indicate if any of the following activities are significantly restricted (e.g., due to pain, weakness, or impaired strength or ability) as a result of the medical conditions for which you are seeking a medical cannabis recommendation:

	Please Mark
Caring for myself
Hearing
Walking
Bending
Learning
Thinking
Social Interaction
Performing manual tasks
Eating
Standing
Speaking
Reading
Communicating
Operation of bodily function
Seeing
Sleeping
Lifting
Breathing
Concentrating
Working
Other

Medications: Please indicate all medications that you are currently taking: _______ None

	Medication	Dosage	Times Per Day	Reason For Taking
1
2
3
4
5
6
7

Please provide a list of any medications to which you have allergies:

	Medication	Type of Reaction
1
2
3
4

Supplements and Vitamins: Please provide a comprehensive list of all the supplements and vitamins you are currently taking, including CBD:

	Supplement/Vitamin	Dosage	Times Per Day	Reason For Taking
1
2
3
4
5
6
7

Please provide specific details about the desired outcomes you hope to achieve by utilizing medical cannabis:

CONSENT TO TREATMENT

AND

ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY

NAME OF PATIENT:

(Please print your name or the name of the patient)

CONSENT FOR TREATMENT: By acknowledging that I (or the patient indicated at the top of this form) seek evaluation and/or treatment at DISTINGUISHED OF BOCA RATON, LLC (referred to as the "Practice"), I voluntarily grant my consent to receive such care. I understand and consent to routine diagnostic procedures, which may include x-rays, blood draws, laboratory tests, medication administration, as well as medical or surgical treatment by physicians and staff members of the Practice, along with other healthcare providers who may be involved in my care as determined necessary by my treating physician. I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me regarding the outcome of my examination or treatment at the Practice. I understand that the treatment provided at the Practice is intended to address specific episodic illnesses or injuries and is not meant to substitute comprehensive care provided by a primary care physician or other specialized healthcare professional.

To maximize the likelihood of successful treatment, I accept the responsibility to follow the advice provided by my treating physician, including compliance with medications/supplements, adherence to discharge instructions, and scheduling follow-up appointments or seeking care from other physicians or an emergency department if my condition significantly worsens. Additionally, I agree to hold the Practice, its managers, employees, and contractors harmless from any liability arising from my failure to comply with the aforementioned conditions. This consent shall remain valid until specifically revoked.

By signing this form, I understand that I am assuming financial responsibility for all medical services and/or supplies that I receive.

At the Practice, patients will receive treatment without discrimination based on race, sex, color, age, national origin, disability, or religion. However, the Practice reserves the right to refuse care to individuals with an outstanding balance, those exhibiting disruptive behavior, or for any other reason at the discretion of the attending physician.

Name of Patient/Patient's Representative:

Signature of Patient/Patient's Representative

Date

Representative's relationship to Patient:

Reason Why Patient Cannot Consent:

Witness

2895 S Federal Highway #B2 Delray Beach, Fl 33483 | 833-356-6537

By signing this consent form, you grant us permission to utilize and disclose your protected health information for treatment, payment, and healthcare operations, unless any specific restrictions are specified below. Protected health information refers to individually identifiable information that we create or receive, including demographic details, information pertaining to your physical or mental health and the provision of healthcare services to you, as well as information related to the collection of payment for services rendered.

Our Notice of Privacy Practices contains detailed information on how we may use and disclose your protected health information. Before signing this consent form, you have the right to receive a copy of our Notice of Privacy Practices. Please note that the terms of our Notice may be subject to change, and if any revisions are made, you can obtain an updated copy by directly contacting us.

You retain the right to request restrictions on the use or disclosure of your protected health information for treatment, payment, or healthcare operations. While we are not obligated to agree to any restrictions, should we agree, we are bound by our agreement. If you wish to make a restriction request, please contact us via email. If you choose not to sign this consent form, we reserve the right to refuse treatment, except in cases where emergency treatment is deemed necessary by a licensed healthcare professional or when treatment is required by law. We are obliged to document any instances in which we proceed with treatment without obtaining your consent, and we will provide you with a copy of this documentation if you decide not to sign this consent form.

You have the right to revoke this consent in writing, except in situations where we have already made disclosures relying on your prior consent. For the purpose of revoking your consent, you may request to use our Authorization for Release of Information Form or simply send us a written letter.

PRINT PATIENT NAME

DATE OF BIRTH

Date

PRINT PATIENT PERSONAL REPRESENTATIVE NAME

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE

DATE OF SIGNATURE

Permission Regarding Disclosure of Your/Your Child's Healthcare Information

I hereby authorize DISTINGUISHED OF BOCA RATON, LLC to speak with the individual(s) named below regarding my or my child's protected health information (optional

Name

Relationship to Patient

Name

Relationship to Patient

2895 S Federal Highway #B2 Delray Beach, Fl 33483 | 833-356-6537

DISTINGUISHED OF BOCA RATON, LLC

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Name of Patient:

Date of Birth:

Date

SS#:

Phone #:

Patient Address:

The undersigned authorizes blanks to release his/her medical records to:

Name:

Address:

Phone Fax:

Please DO NOT release the following:

The undersigned authorizes to release his/her medical records to:

Name:

Address:

Phone Fax:

Please DO NOT release the following:

Medical records include any and all federal and state protected information without limitationto include diagnosis, treatment, and/or examination related to mental healthcare, drug and/or alcohol use, HIV/AIDS testing, and sexually transmitted diseases.
By signing this release, I understand that this authorization will remain in effect for 90 days or until revoked in writing.
I understand that state law prohibits the re-disclosure of the information disclosed to the person/entity listed above without my further authorization, but that DISTINGUISHED OF BOCA RATON, LLC cannot guarantee that the recipient of the information will not re-disclose it.
I hereby release DISTINGUISHED OF BOCA RATON, LLC and its managers, employees and agents from any liability that may arise from the release of information that I have allowed.

SIGNATURE OF PATIENT OR LEGAL GUARDIAN

DATE

Date

2895 S Federal Highway #B2 Delray Beach, Fl 33483

Medical Marijuana Consent Form

The responsibility of obtaining written informed consent cannot be delegated by a qualified physician. The qualified patient or the patient's parent or legal guardian, if the patient is a minor, must personally initial each section of this consent form to acknowledge that the physician has explained the information. Both the qualifying physician and the patient (or parent/legal guardian) must sign and date the informed consent form.

This consent form consists of three parts. Part A is mandatory for all patients and must be completed. Part B is specifically for patients under 18 years of age who have a diagnosed terminal condition and are seeking certification for medical marijuana in smokable form. Part C is the signature block that needs to be completed by all patients.

Part A: Must be completed for all medical marijuana patients - please initial each highlighted blank

a. The Federal Government's classification of marijuana as a Schedule I controlled Substance.

The federal government has classified marijuana as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (1) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana, even in states such as Florida, which have modified their state laws to treat marijuana as a medicine.When in the possession of medical marijuana, the patient or the patient's caregiver must have his or her medical marijuana use registry identification card in his or her possession at all times.

b. The approval and oversight status of marijuana by the Food and Drug Administration.

Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore, the "manufacture" of marijuana for medical use is not subject to any federal standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients, which may vary in potency, impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.

c. The potential for addiction.

Some studies suggest that the use of marijuana by individuals may lead to a tolerance to, dependence on, or addiction to marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think I may be developing a dependency on marijuana, I should contact my certifying physician.

d. The potential effect that marijuana may have on a patient's coordination, motor skills, and cognition, including a warning against operating heavy machinery, operating a motor vehicle, or engaging in activities that require a person to be alert or respond quickly.

The use of marijuana can affect coordination, motor skills, and cognition, i.e., the ability to think, judge and reason. Driving under the influence of cannabis can double the risk of vehicular accident, which escalates if alcohol is also influencing the driver. While using medical marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly and I should not participate in activities that may be dangerous to myself or others. I understand that if I drive while under the influence of marijuana, I can be arrested for "driving under the influence".

e. The potential side effects of medical marijuana use.

Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body's immune system, may affect the production of sex hormones that lead to adverse effects, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of medical marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. Many medical authorities claim that use of medical marijuana, especially by persons younger than 25, can result in long term problems with attention, memory, learning, drug abuse, and schizophrenia.There is substantial evidence of a statistical association between long-term cannabis smoking and worsening respiratory symptoms and more frequent chronic bronchitis episodes. Smoking marijuana is associated with large airway inflammation, increasing airway resistance, and lung hyperinflation. Smoking cannabis, much like smoking tobacco, can introduce levels of volatile chemicals and tar in the lungs that may raise concerns about the risk of cancer and lung disease.I understand that using marijuana while consuming alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.I agree to contact my certifying physician if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact my certifying physician if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.

f. The risks, benefits, and drug interactions of marijuana.

Signs of withdrawal can include: feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to contact my certifying physician immediately or go to the nearest emergency room.Numerous drugs are known to interact with marijuana and not all drug interactions are known. Some mixtures of medications can lead to serious and even fatal consequences. I agree to follow the directions of my certifying physician regarding the use of prescription and non-prescription medication. I will advise any other of my treating physician(s) of my use of medical marijuana.Marijuana may increase the risk of bleeding, low blood pressure, elevated blood sugar, liver enzymes, and other bodily systems when taken with herbs and supplements. I agree to contact my certifying physician immediately or go to the nearest emergency room if these symptoms occur.I understand that medical marijuana may have serious risks and may cause low birth weight or other abnormalities in babies. I will advise my certifying physician if I become pregnant, try to get pregnant, or will be breastfeeding.

g. The current state of research on the efficacy of marijuana to treat the qualifying conditions set forth in this section.

Cancer

There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancers, including glioma. There is evidence to suggest that cannabinoids (and the endocannabinoid system more generally) may play a role in the cancer regulation process. Due to a lack of recent, high quality reviews, a research gap exists concerning the effectiveness of cannabis or cannabinoids in treating cancer in general.
There is conclusive evidence that oral cannabinoids are effective anti-emetics in the treatment of chemotherapy-induced nausea and vomiting. There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancer associated anorexia cachexia syndrome and anorexia nervosa.

Epilepsy

Epilepsy There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for epilepsy. Recent systematic reviews were unable to identify any randomized controlled trials evaluation the efficacy of cannabinoids for the treatment of epilepsy. Currently available clinical data therefore consist solely of uncontrolled case series, which do not provide high- quality evidence of efficacy. Randomized trials of the efficacy of cannabidiol for different forms of epilepsy have been completed and await publication.

Glaucoma

There is limited evidence that cannabinoids are an ineffective treatment for improving intraocular pressure associated with glaucoma. Lower intraocular pressure is a key target for glaucoma treatments. Non-randomized studies in healthy volunteers and glaucoma patients have shown short-term reductions in intraocular pressure with oral, topical eye drops, and intravenous cannabinoids, suggesting the potential for therapeutic benefit. A good-quality systemic review identified a single small trial that found no effect of two cannabinoids, given as an oromucosal spray, on intraocular pressure. The quality of evidence for the finding of no effect is limited. However, to be effective, treatments targeting lower intraocular pressure must provide continual rather than transient reductions in intraocular pressure. To date, those studies showing positive effects, have shown only short-term benefit on intraocular pressure (hours), suggesting a limited potential for cannabinoids in the treatment of glaucoma.

Positive Status for Human Immunodeficiency Virus

There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS. There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as effective treatments for AIDS wasting syndrome.

Acquired Immune Deficiency Syndrome

There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS. There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as effective treatments for AIDS wasting syndrome.

Post Traumatic Stress Disorder

There is limited evidence (a single, small fair-quality trial) that Nabilone is effective for improving symptoms of post traumatic stress disorder. A single, small crossover trial suggests potential benefit from the pharmaceutical cannabinoid Nabilone. This limited evidence is most applicable to male veterans and contrasts with non-randomized studies showing limited evidence of a statistical association between cannabis use (plant derived forms) and increased severity of post-traumatic stress disorder symptoms among individuals with post traumatic stress disorder. There are other trials that are in the process of being conducted and if successfully completed, they will add substantially to the knowledge base.

Amyotrophic Lateral Sclerosis

There is insufficient evidence that cannabinoids are an effective treatment for symptoms associated with amyotrophic lateral sclerosis. Two small studies investigated the effect of Dronabinol on symptoms associated with ALS. Although there were no differences from placebo in either trial, the sample sizes were small, the duration of the studies was short, and the dose of Dronabinol may have been too small to ascertain any activity. The effect of cannabis was not investigated.

Crohn's Disease

There is insufficient evidence to support or refute the conclusion that Dronabinol is an effective treatment for the symptoms of irritable bowel disease. Some studies suggest that marijuana in the form of cannabidiol may be beneficial in the treatment of irritable bowel diseases, including Crohn's Disease.

Parkinson’s Disease

There is insufficient evidence that cannabinoids are an effective treatment for the motor system symptoms associated with Parkinson’s Disease or the levodopa-induced dyskinesia. Evidence suggests that the endocannabinoid system plays a meaningful role in certain neurodegenerative processes; thus, it may be useful to determine the efficacy of cannabinoids in treating the symptoms of neurodegenerative diseases. Small trials of oral cannabinoid preparations have demonstrated no benefit compared to placebo in ameliorating the side effects of Parkinson’s disease. A seven patient trial of Nabilone suggested that it improved the dyskinesia associated with levodopa therapy, but the sample size limits the interpretation of the data. An observational study demonstrated improved outcomes, but the lack of a control group and the small sample size are limitations.

Multiple Sclerosis

There is substantial evidence that oral cannabinoids are an effective treatment for improving patient-reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on clinician-measured spasticity. Based on evidence from randomized controlled trials included in systematic reviews, an oral cannabis extract, Nabiximols, and orally administered THC are probably effective for reducing patient-reported spasticity scores in patients with MS. The effect appears to be modest. These agents have not consistently demonstrated a benefit on clinician-measured spasticity indices.

Medical Conditions of the Same Kind or Class as or as Comparable to the Above Qualifying Medical Conditions

The qualifying physician has provided the patient or the patient’s caregiver a summary of the current research on the efficacy of marijuana to treat the patient’s medical condition.
The summary is attached to this informed consent as Addendum A.

Terminal Conditions Diagnosed by a Physician Other Than the Qualified Physician Issuing the Physician Certification

The qualifying physician has provided the patient or the patient’s caregiver a summary of the current research on the efficacy of marijuana to treat the patient’s terminal condition.
The summary is attached to this informed consent as Addendum A.

Chronic Nonmalignant Pain

There is substantial evidence that cannabis is an effective treatment for chronic pain in adults. The majority of studies on paid evaluated Nabiximols outside the United States. Only a handful of studies have evaluated the use of cannabis in the United States, and all of them evaluated cannabis in flower form provided by the National Institute on Drug Abuse. In contrast, many of the cannabis products that are sold in state-regulated markets bear little resemblance to the products that are available for research at the federal level in the United States. Pain patients also use topical forms. While the use of cannabis for the treatment of pain is supported by well-controlled clinical trials, very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.

h. That the Patient’s De-Identified Health Information Contained in the Physician Certification and Medical Marijuana Use Registry May be Used for Research Purposes.

The Department of Health submits a data set to the Consortium for Medical Marijuana Clinical Outcomes Research for each patient registered in the Medical Marijuana Use Registry that includes the patient’s qualifying medical condition and the daily dose amount and forms of marijuana certified for the patient.

PART B: Ordering smokable marijuana for a terminal patient under 18.

Initial here if you are not a terminal patient under 18 who will be receiving medical marijuana in a smokable form. After initialing here, complete Part C.If the patient is under 18, has a terminal condition, and will be receiving medical marijuana in a smokable form, please review and initial the remainder of Part B before completing Part C.

Respiratory Health

Exposure to tobacco smoke and household air pollution consistently ranks among the top risk factors not only for respiratory disease burden but also for the global burden of disease. Given the known relationships between tobacco smoking and multiple respiratory conditions, one could hypothesize that longterm cannabis smoking leads to similar deleterious effects of respiratory health, and some investigators argue that cannabis smoking may even be more harmful than that of tobacco smoking. Data collected from 15 volunteers suggest that smoking one cannabis joint can lead to four times the exposure to carbon monoxide and three to five times more tar deposition than smoking a single cigarette.

Cognitive and Psychosocial Development

Researchers are still studying the long term health effects of marijuana. Most people agree that marijuana use hurts adolescents more than adults. It is during the period of adolescence and young adulthood that the neutral substrates that underlie the development of cognition are most active. Adolescence marks one of the most impressive stretches of neural and behavioral change with substantial protracted development in terms of both brain structure and function. As a result, cannabis and other substance use during this period may incur relatively greater interference in neural, social, and academic functioning compared to late developmental periods.

There is moderate evidence of a statistical association between acute cannabis use and impairment in the cognitive domains of learning, memory and attention.
There is limited evidence of a statistical association between sustained abstinence from cannabis use
and impairments in the cognitive domains of learning, memory and attention.
There is limited evidence of a statistical association between cannabis use and impaired academic achievement and education outcomes.
There is limited evidence of a statistical association between cannabis use and increased rates of unemployment and/or low income.
There is limited evidence of a statistical association between cannabis use and impaired social functioning or engagement in developmentally appropriate social roles.
Less blood flow to parts of the brain.

Addiction

Marijuana, like some other brain-altering substances, can be addictive. Nearly one in 10 marijuana users will become addicted. Starting to use marijuana at a younger age can lead to a greater risk of developing a substance use disorder later in life. Adolescents who begin using marijuana before age 18 are four to seven times more likely than adults to develop a marijuana use disorder.

PART C: Except for patients diagnosed with a terminal condition, this certification authorizes smoking marijuana as an appropriate method of administration for a qualified patient.

Acknowledgement of contaminant risks.

Smokable marijuana has infectious risks that are not present in processed products. Certain molds or mildews can contaminate marijuana plants during growing, processing, storage in dispensaries and in patient homes. These contaminants can pose health risks, particularly to those who are immunosuppressed due to their disease state and treatments. While the State of Florida requires third party testing you should still you’re your product.

Respiratory Health.

Exposures to tobacco smoke and household air pollution consistently ranks among the top risk factors not only for respiratory disease burden but also for the global burden of disease. Given the known relationships between tobacco smoking and multiple respiratory conditions, one could hypothesize that long-term cannabis smoking leads to similar deleterious effects of respiratory health, and some investigators argue that cannabis smoking may even be more harmful than that of tobacco smoking.

Information regarding health risks of 2nd and 3rd hand smoke to other household members.

You should never smoke medical marijuana around other family members, especially children and any household guests. You should smoke outside to allow adequate ventilation and to mitigate the dangers of secondhand and thirdhand smoke to others. Marijuana should never be smoked inside vehicles or other small spaces that children will occupy even if the children are not present at the time the product is consumed.

Dangers of smoking marijuana in households where oxygen is in use.

If you use oxygen or have others in your household who use oxygen you should not smoke marijuana or any other combustible material in the vicinity of where the oxygen is in use due to the risk of fire and explosion.

Self-dosing, if permitted.

I have been given instructions or discussed guidance on self-dosing with my qualified physician if permitted to do so.

PART D: Must be completed for all medical marijuana patients

I have had the opportunity to discuss these matters with my certifying physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that my certifying physician has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana.

I have been provided with detailed information by my certifying physician regarding the potential risks, complications, and anticipated benefits associated with the recommended treatment. This includes the likelihood of both successful outcomes and possible failures. I acknowledge that my certifying physician has thoroughly discussed any alternative treatment options, including the option of no treatment, and has explained the associated risks and benefits. Furthermore, my certifying physician has provided a comprehensive explanation of the content outlined in this consent form regarding the medical utilization of marijuana.

Patient (print name):

Patient signature or signature of the parent or legal guardian if the patient is a minor – please sign and date:

Date

I have explained the information in this consent form about the medical use of marijuana to blanks (print patient name).

Qualified Physician Signature:

Date

Witness

Date

Generalized Anxiety Disorder 7-Item (GAD-7) Scale

Over the last 2 weeks, how often have you been bothered by the following problems? (Please circle your response)

	Not at all	Several days	Over half the days	Nearly every day
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

Score (Not at all)

Score (Several days)

Score (Over half the days)

Score (Nearly every day)

Total Score add (your column scores) =

If you checked off any problems, please indicate how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Source: Spitzer, RL, et. al., A brief measure for assessing generalized anxiety disorder, Archive of Internal Medicine, 2006:166, 1092-1097

Over the last 2 weeks, how often have you been bothered by the following problems? (Please circle your response)

	Not at all	Several days	Over half the days	Nearly every day
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 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

Score (Not at all)

Score (Several days)

Score (Over half the days)

Score (Nearly every day)

Total Score =

If you checked off any problems how difficult have they made it for you to do your work take care of things at home or get along with other people

The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the last 12 months. "Drug Abuse" refers to:

i) the use of prescribed or over-the-counter drugs in excess of their directions; and

ii) any non-medical use of drugs. The various classes of drugs may include cannabis, solvents, tranquilizers, barbiturates, cocaine, stimulants, hallucinogens or narcotics not alcoholic beverages.

Please circle the best response for every question unless you have answered no to Question 1.

In the past 12 months

1. Have you used drugs other than those required for medical reasons?

If yes, explain

2. Do you abuse more than one drug at a time?

If yes, explain

3. Are you unable to stop abusing drugs (if you abuse them) when you want to?

If yes, explain

4. Have you ever had blackouts or flashbacks as a result of drug use?

If yes, explain

5. Do you ever feel bad or guilty about your drug use?

If yes, explain

6. Does your spouse (or parents) ever complain about your drug use?

If yes, explain

7. Have you neglected your family because of your drug use?

If yes, explain

8. Have you engaged in illegal activities in order to obtain drugs?

If yes, explain

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

If yes, explain

10. Have you had medical problems as a result of your drug use: i.e. memory

If yes, explain

loss hepatitis convulsions bleeding

Scoring: Score 1 point for each question answered "Yes" Score:

Score

ScoreDegree of Problems Related to Drug Use 0No problems reported 1-2Low level Moderate level Substantial level 9-10Severe level

Suggested Action None at this time Monitor, reassess at a later date Further investigation Intensive assessment

Positive Status for Human Immunodeficiency Virus

There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS. There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as effective treatments for AIDS wasting syndrome.

FL-MMJ-DR

PATIENT MEDICAL HISTORY INTAKE FORM

DISTINGUISHED OF BOCA RATON, LLC

2895 S Federal Highway #B2 Delray Beach, Fl 33483 | 833-356-6537

DISTINGUISHED OF BOCA RATON, LLC

IF SENDING RECORDS TO US, PLEASE FAX TO: (919) 324-1828

IF THE RECORDS ARE MORE THAN 30 PAGES, KINDLY MAIL TO THE LOCATION BELOW

PATIENT HEALTH QUESTIONNAIRE - 9 (PHQ-9)

DRUG ABUSE SCREENING TEST (DAST-10)