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Patient Renewal
Patient Identification Information
Name
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E-mail
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Mailing Address
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City, State, Zip
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Date of Birth
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Home Phone
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Psychiatric Issues (Anxiety, Bipolar Disorder, Depression, PTSD, etc.):
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Insomnia:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Arthritis, any joint(s):
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Back Pain:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Neck Pain
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Fibromyalgia / Chronic Fatigue Syndrome:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Hepatitis:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Headache:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Heartburn:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Dysmenorrhea (painful menstrual periods):
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Seizure Disorder:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Cancer, currently being treated:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Chronic pain of any type, please specify location under current symptons below:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Auto Immune Disorders, please specify type under current symptoms below:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Glaucoma:
Same
Better
Worse
New Health Issue
Current Symptoms / Medications, please list:
Tobacco / Alcohol / Drug use
Current alcohol use (type, how often, how much):
Current amount of cigarettes / chewing tobacco used per day:
Any other drug use? Please explain:
Please add any other concerns / medical conditions not listed above:
Include any new health issues that have come up since your last appointment.
Include any issues or side-effects experienced with Medical Cannabis.
Describe your current living situation (alone or not, pets, etc.):
How do you use Medical Cannabis (in food, pipe, etc.)?:
Please include frequency of use.