New Cannabis Patient Intake

First Name

Patient Date of Birth

Middle Name

Patient E-mail

Last Name

Patient SSN

Patient Street Address

Must match official ID

Patient Home Phone

Patient City

Patient Cell Phone

Patient State

Your PREFERRED Contact

Patient Postal Code

You give PERMISSION to contact via

Home Phone

Cell Phone

E-Mail

Check all that apply

Guardian/Caretaker First Name

Guardian/Caretaker Date of Birth

Guardian/Caretaker Middle Name

Guardian/Caretaker E-mail

Guardian/Caretaker Last Name

Guardian/Caretaker SSN (last 4)

Guardian/CaretakerStreet Address

(If different from patient.) Must match official ID.

Guardian/Caretaker Home Phone

Guardian/Caretaker City

Guardian/Caretaker Cell Phone

Guardian/Caretaker State

Guardian/Caretaker PREFERRED Contact

Guardian/Caretaker Postal Code

Guardian/Caretaker gives PERMISSION to contact via

Home Phone

Cell Phone

E-Mail

Check all that apply

How did you hear about us?

Friend/Family Member

Physician/Clinician Referal

If you were referred by a personal friend or professional contact, please include their name and contact information so we can thank them.

Current Occupation

Do you have a CDL license?

Yes No

Did you serve in the US Armed Forces

Yes No

If yes, what branch?

If yes, what is your discharge status?

Is this your

Initial Certification Recertification

Have you already been diagnosed with a qualifying condition?

Yes No

Please include any details that would help us better understand your condition.

Include onset, type, frequency and severity of symptoms. Include any hospitalizations, diagnostic results or medical visits. If already diagnosed please include who diagnosed it and how (i.e. my primary care physician with blood tests)

Past Medical History

Include anything you have received treatment for, are receiving treatment for or should receive treatment for. You may also include anything else that would help us explain your condition, including illness, trauma, emotional stress, addictions, drug abuse, or anything you feel is pertinent.

List any food, medication or environmental allergies.

Include reaction, for example - strawberries = rash, penicillin = throat swelling

Medications (include dose & frequency)

Include prescriptions, over the counter and herbal supplements. Please make a note if any are new. If none, write none.

Are you currently on Methadone or Suboxone?

Yes No

If yes, please list the methadone or Suboxone clinic where you are seeking treatment.

In order to qualify for evaluation with Mindful Medicine, we will need to discuss your care with you and your clinic to ensure that you are receiving the proper treatment. You have come far in your recovery and we want to ensure that you continue to recover and make a smooth transition with medical marijuana. (*You will need to ask the methadone/suboxone clinic to release a note to us saying you are under their care. This is not optional if you wish to become a cannabis patient at Mindful Medicine.

Name/Contact of Primary Care physician

If none, write "none"

Name any specialist you see, their specialty, why you see them, and when you last saw them.

*For example, Dr. Smith - Orthopedic Surgeon - knee replacement, last seen 2014

Are you currently pregnant?

Yes No

Are you planning on getting pregnant in the near future?

Yes No

Are you currently breast feeding?

Yes No

SOCIAL HISTORY
This helps to better understand you. Your answers no NOT disqualify you from becoming a medical marijuana patient.

Do you/have you ever smoked cigarettes, cigars or pipes?

Never Former Current

If yes, how heavily and for how long?

Do you drink alcohol?

Never Former Current

If yes, what is your preferred drink. How often do you drink? How much do you drink at a time?

Have you ever used cannabis?

Yes No

Do you currently use cannabis?

Yes No

If you are currently using cannabis, how often do you use/medicate?

Has cannabis ever caused a bad reaction?

i.e. racing heart, anxiety, paranoia, excessive sleep)

Past Cannabis Use

Please explain your experience with cannabis, whether it was recreational, medical or self medicating. If it has helped with pain, please explain how it helped. How much did you need to use (if you are unsure, think in terms of more or less than those around you). If it caused anxiety or racing heart, please explain that as well. List both positive and negative experiences. This will help tailor the recommendations to your personal needs. If you have never tried cannabis previously, just write N/A.

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