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New Patient
Patient Identification Information
Name
*
Last First M.I.
Mailing Address
*
City, State, Zip
*
Home Address
I identify my gender as
*
What pronoun do you identify with?
*
Height
Weight
Date of Birth
*
Age
*
Home Phone
*
Cell Phone
Work Phone if OK to contact you there
Email
*
Relationship Status
(single, married, etc.)
Highest Level of formal education
Occupation
Retired?
Disabled? (date)
Emergency Contact
*
Phone
*
Family Doctor / Provider
Medical History
Surgeries (List type and date)
Medical Illnesses (specify past and current and if resolved)
Psychological Illness and/or treatment, including counseling (specify past and current)
Trauma: vehicle accidents, falls, etc.
Medications: list (specify past and current)
Allergies to any medications (list)?
I am:
married, living with spouse
single
Other...
I am: Other...
Who do you live with?
alone
husband
wife
housemate(s)
significant other
relatives or pets, specify
Who do you live with? relatives or pets, specify
Cigarette use
never smoked
how many cigarettes per day?
Cigarette use how many cigarettes per day?
age began:
age quit:
Chewing Tobacco: how much per day?
Alcohol use: How often and what type/amount of alcohol do you consume?
How much of what exercise do you do? (please include frequency)
Mother:
Alive
Deceased
Age:
Illnesses:
Father:
Alive
Deceased
Age:
Illnesses:
Siblings: How many brothers?
Siblings: How many sisters?
Any diseases?
Children (ages, sex & health)
Is there a family history of high cholesterol, diabetes, high blood pressure, cancer, drug abuse, early heart disease, arthritis, psychiatric disease?
Yes
No
Please specify which condition and in which relative:
Are your parents divorced?
Yes
No
If so, how old were you and who raised you?
Were you raised as a child in an alcoholic or abusive home?
Yes
No
Who?
Mother
Father
Step-parent
Other, please specify
Who? Other, please specify
Medical History II
Head, eyes, ears, teeth, jaw, nose or throat
Headaches
Migraines
TMJ (jaw joints)
Other, please specify
Head, eyes, ears, teeth, jaw, nose or throat Other, please specify
Have you been checked for glaucoma?
Yes
No
If so, when?
Was your eye pressure elevated?
Yes
No
Reading, if known
Chest:
Asthma (wheezing)
Heart murmur
Vascular Disease
Leg cramps with exertion
Exercise limitations
Swelling
Cholesterol
High blood pressure
Other, please specify
Chest: Other, please specify
Stomach, liver, gall bladder, intestines, pancreas:
Poor appetite
Weight gain or loss
Pains
Ulcer
Reflux
Nausea
Diarrhea
Constipation
Change in bowel habits
Bleeding
Stool blood test
Other, please specify
Stomach, liver, gall bladder, intestines, pancreas: Other, please specify
Have you ever had Hepatitis?
Yes
No
If so, what kind:
A
B
C
Have you had a liver biopsy?
Yes
No
Have you ever had treatment for hepatitis?
Yes
No
Results of treatment:
Genital, Female
Menstrual Pain
Endometriosis
PID
HIV
Other
Genital, Female Other
Menses (period): Age at onset
Duration/frequency
regular?:
Yes
No
PAP smear (date)
Mammogram (date)
Pregnancy History: Live Births
number
Abortions or miscarriages:
number
Prostate (Men): Rectal exam (year)
PSA blood test (year):
Prostate trouble (please specify):
Kidney and Bladder:
Infection
Stone
Incontinence
Other
Kidney and Bladder: Other
Neurologic:
MS
Neuropathy
Paralysis or weakness
Numbness
Tremor
Stroke
Chronic fatigue
Other
Neurologic: Other
Chronic Pain:
Arthritis
Low back pain or sciatica
Neck Pain
Arm or hand pain or numbness
Shoulder
Wrist
Hand
Hip
Knee
Ankle
Foot pain
Fibromyalgia
Other
Chronic Pain: Other
Have you had X-rays/CT/MRI of:
Neck
Back
Shoulder
Knee
Other
Have you had X-rays/CT/MRI of: Other
Please explain:
Psychological:
Counseling or Therapy
Depression
Insomnia
Bulimia
Anorexia
Paranoia
Bipolar
Anxiety
Panic
Suicidal Thoughts or Attempts
Memory Problems
Social Isolation
Anger
Poor job performance or inability to maintain a job
Unsatisfactory Relationships
Other
Psychological: Other
Seizure disorder
Cancer, currently being treated
Chronic pain of any type not above, please specify symptons
Auto immune disorders, please specify location, etc.
Glaucoma
Effects of Cannabis & Other Drugs
When using Cannabis, do you ever experience:
Paranoia
Heart Pounding
Anxiety
Loss of Dreams
Weight Gain
Depression
Sleep Disturbances
Munchies
Other
When using Cannabis, do you ever experience: Other
Have you been prescribed or have you used:
Aspirin, Advil, Aleve, etc.
Percodan or Percocet
Opiates
Vicodin
Oxycontin
Codeine
Morphine
Methadone
Suboxone
Other
Have you been prescribed or have you used: Other
Prescribed or non-prescription anti-nausea medication?:
Zofran
Compazine
Phenergan
Other
Prescribed or non-prescription anti-nausea medication?: Other
Antidepressants:
Celexa or Lexapro
Luvox
Zoloft
Elavil
Prozac
Paxil
Effexor
Trazodone
Other
Antidepressants: Other
Anti-anxiety Drugs
Valium
Xanax
Klonopin
Ativan
Halcion
Ambien
Other
Anti-anxiety Drugs Other
Seizure-type drugs:
Neurontin
Depakote
Inderal or Propanolol
Other
Seizure-type drugs: Other
If you desire to become pregnant, or nurse, would you stop Cannabis use?
What precautions do you take to prevent unauthorized use of your Cannabis?
ie: lockbox, etc.
Cannabis Use
Age when you began using Cannabis?
Under 20
20-30
30-40
Over 40
Recently
Why did you use Cannabis?
Recreational
Relieve Anxiety
Physical Pain
Help me: function, focus, relate
Other
Why did you use Cannabis? Other
Preferred method of use:
Water pipe / bong
Pipe
Joint
Food
Tincture
Sublingual Spray / tincture
Vaporizer
Dabs
Fresh Leaves
Full extract cannabis oil (FECO)
On average, how often do you use Cannabis?
Daily
Weekly
Monthly
Other
On average, how often do you use Cannabis? Other
How much Cannabis do you consume with each use?
less than a gram
1-2 grams
3-4 grams
over 4 grams
Have you ever had a marijuana recommendation before?
Yes
No
In California?
Yes
No
Have you ever been involved in legal action for any illegal drug or alcohol use?
Yes
No
If yes, please explain
Are you on Probation?
Yes
No
If yes, until what date?
Are you involved in any work or court required drug testing?
Yes
No
Have you ever been involved in a drug or alcohol treatment program?
Yes
No
If yes, please give dates
Have you ever had problems related to your cannabis use? Explain:
Has anyone suggested your cannabis use is a problem? Explain:
Have you ever been involved in any legal action regarding Cannabis?
Are you currently involved in any Cannabis legal action?
Medical Conditions for which I use Cannabis
Please include a summary in your own words describing your complaints, symptoms or medical conditions you are being seen for. Include your experience with other types of treatments and/or therapies and why Cannabis is preferable to you.
Description:
I affirm that the above information is true and accurate to the best of my knowledge, and that any recommendation, certification, or approval associated with my use of Cannabis is contingent upon the accuracy of this information:
affirmation
*
Yes
