New Cannabis Patient Intake

Must match official ID
Check all that apply
(If different from patient.) Must match official ID.
Check all that apply
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)
Choose all the apply
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.
Include reaction, for example - strawberries = rash, penicillin = throat swelling
Include prescriptions, over the counter and herbal supplements. Please make a note if any are new. If none, write none.
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.
If none, write "none"
*For example, Dr. Smith - Orthopedic Surgeon - knee replacement, last seen 2014

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

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


These days, social proof is everything. If you have had a good experience at Mindful Medicine Clinic, we would really appreciate it if you shared!

All information contained on this website is intended for informational and educational purposes only, and is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition.