Patient Renewal

Patient Identification Information

Name *

E-mail *

Mailing Address *

City, State, Zip *

Date of Birth *

Home Phone *

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.