Kentucky Med Card Patient Intake Form

Kentucky Med Card Patient Intake Form

Please complete the information below to help us prepare for your medical cannabis evaluation and streamline your appointment experience with Family Psychiatric Services. All required sections must be completed before the form can be submitted.
Personal Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Home Address

Street Address

Street Address Line 2
CityState Zip Code
Contact Info
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (required)
example@example.com
Identity Verification
Social Security Number (SS#)
Driver's License Number
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical Section
List your Current Medications
Provide the Name, Dose and How often your take your medication. Also include herbal supplements and vitamins.
Do you have any allergies?
Please list any allergies and reactions:
Medical & Surgical History
Have you ever been diagnosed with any of the following medical conditions? Please select all that apply.
Surgical History
Please list any past surgeries, including approximate dates if known:
Psychiatric & Substance Use History
Have you ever been diagnosed with any of the following mental health conditions? Please select all that apply.
Suicidality: Please describe any past or current suicidal thoughts, suicide attempts, self-harm behaviors, or psychiatric hospitalizations. If none, please write N/A.
Please describe any family history of medical conditions, mental health conditions
Substance Abuse History

Please indicate any substances you currently use or have used in the past. Describe how much and when you last used each substance, if applicable.
Please select any substances you currently use or have used in the past (if applicable):
Last time used
How much used
Please select any substances you currently use or have used in the past (if applicable):
Last time used
How much used
Please select any substances you currently use or have used in the past (if applicable):
Last time used
How much used
Please select any substances you currently use or have used in the past (if applicable):
Last time used
How much used
Please select any substances you currently use or have used in the past (if applicable):
Last time used
How much used
Please select any substances you currently use or have used in the past (if applicable):
Last time used
How much used
Qualifying Diagnosis

Which qualifying diagnosis or medical condition are you seeking evaluation for today?
Please select one of the following Kentucky-approved qualifying medical conditions below:
Upload Medical Records for Your Qualifying Condition

Please upload any medical records that support your qualifying condition.
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Please describe your medical condition in your own words
Use as much detail as possible to describe your condition.
When did your symptoms or condition first begin? Please include any known cause, injury, illness, or event related to when this started.
Give the date to the best of your recollection.
Please identify the area(s) of your body or health condition affected by your symptoms:
Are your symptoms constant, intermittent, or triggered by certain activities or situations?
Please describe how your symptoms affect your pain levels, emotions, sleep, appetite, daily functioning, work, relationships, or social activities:
Do you notice anything that triggers or aggravates your symptoms?
What tends to improve your symptoms or make them easier to manage?
How has this condition affected other parts of your body, your emotional well-being, daily activities, work, sleep, relationships, or overall quality of life?
Are the symptoms more intense after waking up, during the day, at night, or during certain weather or seasonal changes?
How severe are your symptoms on a scale of 1 to 10?
(1 = very mild, 10 = extremely severe)
Schedule Your Med Card Evaluation

Select a convenient appointment time to complete your Kentucky medical cannabis evaluation with Family Psychiatric Services during the patient drive.
Kentucky Medical Cannabis Appointment Scheduling

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Med Can Patient Drive

Medical Cannabis Evaluation and Certification Appointment for patients seeking a Kentucky medical cannabis card. This visit includes a clinical evaluation, review of qualifying conditions, discussion of symptoms and treatment history, education regarding medical cannabis, and completion of state-required certification documentation when appropriate under Kentucky guidelines.

$25.00 Quantity

Total

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Kentucky Med Card Patient Intake Form

Personal Information

Contact Info

Identity Verification

Emergency Contact

Medical Section

Medical & Surgical History

Psychiatric & Substance Use History

Substance Abuse History

Qualifying Diagnosis

Schedule Your Med Card Evaluation

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