Medical History Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social security number
*
What is your DOB?
*
MM/DD/YY
What is your gender?
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Check the conditions that apply to you:
Chronic pain
Cancer
Intractable seizure disorder
Muscle spasms or spasticity
Multiple sclerosis
Post-traumatic stress disorder
Epilepsy
Chronic nausea or cyclic vomiting syndrome
Medical History
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list all medications
Do you now use or have you ever used any kind of tobacco?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
*
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
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Treatment Effectiveness for Qualifying Condition
Please answer the following questions on how effective your current treatment plan is for your medical condition.Current treatments (medications, therapy, etc…) for your medical condition:
*
How effective are these in your treatment?
*
Not at all
Mild
Moderate
Significant
For individuals renewing their medical cannabis card:
How effective is medical cannabis in your treatment?
Not at all
Mild
Moderate
Significant
Have you been convicted of a felony
*
yes
no
if you answered yes to the last question, what was the felony conviction charge?
I certify the above information is true and correct:
Signature
Submit
Submit
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