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Form for you & your doctor to determine 
medical eligibility for medical marijuana,

THE FOLLOWING SURVEY/FORM IS DESIGNED TO AID 
THE DOCTOR WHO WILL REVIEW IT FOR YOUR ELIGIBILITY TO 
DETERMINE IF YOU QUALIFY FOR A WRITTEN RECOMMENDATION/
PERMISSION TO USE MEDICAL CANNABIS IN THOSE STATES THAT
 ALLOW COMPASSIONATE USE/ CULTIVATION....

Return Back To Main Medical Page

PLEASE TRY TO BE AS COMPLETE AS POSSIBLE WHEN FILLING 
OUT THIS SURVEY/FORM. ALL QUESTIONS ARE OPTIONAL. WE RESPECT
 YOUR RIGHTS TO PRIVACY. THIS FORM WILL BE ONLY RELEASED TO A 
DOCTOR WITH YOUR PRIOR APPROVAL, AND WILL REMAIN CONFIDENTIAL 
WHILE IT RESIDES WITH THE REFERRAL SERVICE. WE WILL DELETE THIS INFORMATION FROM OUR FILES AT ANY TIME YOU MAY DIRECT US TO DO SO.....

 

REFERRED TO US BYTODAY'S DATE:

SEARCH ENGINE USED

VISIT SITE

PERSONAL INFORMATION:

Last name: First Name:

MI

Street Address

CityState

ZipperHome Phone

workfax

Best times to reach you:

Pager E-MailBirthdate

SexMaleFemaleTrans:

Marital Status: MarriedSingleDivorcedSeparatedWidowed

Domestic PartnerPresently: Weight Height

 

DEMOGRAPHIC INFORMATION:

Employment: full timepart timeunemployedretiredDisabled

Date last worked Date of InjuryYears of Education1011

121314151617 Degree(s) obtained:

Other training

Major or area of speciality

Milatary: yesno Highest RankLength Service

FromToService in Viet Namyesno

Branch of Service:NavyArmyMarinesAir forceCoast Guard

MOS:

Citations:

Discharge:

Occupation(s):

Living Situation:Alonemarriedcouplegroup--withparents

children--in a(n)houseapartmentinstitutionhomeless

Your religionParents

Birth Order: Born 1st2nd3rd4th5th6th7th

Out of:1234567 Children

FAMILY MEDICAL HISTORY:

Mother:alivedeceased at age Mothers medical history

includes:cancerhypertensionheart diseasediabetes

mental disordersalcohol abuseother drug problems

Father:alivedeceasedat age Fathers medical history

includes:cancerhypertensionheart diseasediabetes

mental disordersalcohol abuseother drugs

Age(s) and health of brothers and sisters:

Are you an adult child of an alcoholic or abuse family?yesno

PAST MEDICAL HISTORY:

Allergies: Food:

Medications:

Other:

List any past illnessess and/or surgeries:

In the past 6 years have you:

Had any fractures or dislocations:yesno

Explain:

Been injured in a traffic accident:yesno

Explain:

Injured your head:yesno

Explain:

Been injured in a fight or assault:yesno

Explain:

Been injured while or after consuming alcoholyesno

Explain:

PRESENT ILLNESS:

List, in order of seriousness, the diseases,conditions,

or symptons you medicate with cannabis.

Primary Illness:

For Illness #1, date of injury or onset:

Course (include: surgeries, medications,prescribed

treatments and results,alternative care, etc...) be as

accurate and complete as possible...

Secondary Illness:

For Illness #2, date of injury or onset:

Course (include: surgeries, medications, prescribed

treatments and results, alternative care, etc..) be

as complete and accurate as possible:

CANNABIS USE PATTERNS:

At what age did you first use cannabis?

In what year?At what school year?

Do you believe your grades were affected?yesno

Expain:

Was your first use social?yesno

Did you notice the effects?yesno

Did it take numerous times to feel the effects?yesno

Did you have a favorable reaction?yesno

Did you have an unfavorable reaction?yesno

Explain:

Cannabis types preferred: IndicaSativaSinsemilla

MexicanHashno preferrence other, if other specify,

List "street name" varities used that have helped you.

When and how did you first discover it helped your symptons?

Have you ever cooked with cannabis?yesno

Has it helped you more than smoking?yesno,

Explain:

Which come first, mental effectsphysical relief?

By:secondsa minuteseveral minutes15minutes

30 minutes1 hour90 minutes or longer.

Preferred method of cannabis intake?OralJoint,

pipewater pipevaporizerhookacooking

If other, please list:

How often do you use cannabis?1x/month2x/month,

1x/week2-3x/week1x/day2x/day3x/day4x/day

more than 4x/day. If more than 4x/day please explain:

How many grams of cannabis do you use per week?1gm.

2gm3-5gm6-8gm.9-12gm. or moregm.per week.

Has your consumption changed in the past six months?

increasedecresedno change If increased how do

you contribute the change?

Will you cultivate your own medicineyesno.

Do you have to buy your medicine from the streets,

or off the "black market"yesno.

Would you prefer buying from a Med-Mj club?yesno.

Do you have a club with-in driving distance?yesno.

What prices are you now paying for your medicine?

Explain:

Would you use more if it were easier to obtain?yesno,

How much more?25%50%75%100%

Would you use more if it were cheaper?yesno,

How much more?25%50%75%100%

Overall, how does cannabis affect your conditon/

symptoms? Cannabis makes them(check best answer)

much bettera little betterno effecta little worse,

much worse. If other please explain,

.

What if any negative side effects have you encountered?

.

Have you experienced any swings in weight change?

.

Have you ever discountinued your cannabis and found

a worsening or return of symptoms, explain:

Have you ever used Marinol (synthetic THC):yesno

What symptom was it used for?

Results:

List any other medical reasons for which you use cannabis:

Are there non-medical reasons for which you use cannabis?

Check all that may apply:To get "high"to improve mood,

change attutudeto relaxstress reliefto increase energy,

Religious or spiritualOther,.

OTHER MEDICATIONS AND DRUGS:

Prescribed and over the counter medicines and herbs used

to treat condition(s) for which cannabis is used:

List in order: Name of medication, presently use, no longer use,

Reason for discontinuing, Cost of medication per month.

Prescribed and over the counter medicines and herbs

used to treat other condition(s): List in order:

Name of medication,presently use,no longer use, reason for

dicontinuing, cost of medication per month.

Non-medical pschoactive drugs, include: Alcohol,

drinks per week, Tobacco:Cigaretes per day,

Cocaine/Amphetamine:times per month, Herion and

opiates:times per month, LSD-Ecstacy-Psilicybe,

times per month.Other

Side effects: How do the unwanted side effects of cannabis

compare to those of your prescription drugs? Check the

best answer: Cannabis has:morethe sameless

unintended side effects.

Physician or Medical Institution Attitude/Policy:

Not Applicable, I do not have a physician.

Have you dicussed medical marijuana with your primary physician?

yesno. With your HMO or Groupyesno. If no why not?

If yes, how did he/she respond?

YOUR DOCTORS INFORMATION:

Primary physician: Name

Telephone #

CityState

Address

Specialist: Name:

Telephone

CityState

Address

Would you be interested in taking part in a cannabis

related research study? yes no MedicoLegal

Are you on probation or parole? yes no

Explain:

Do you have a pending cannabis case?

yes no, Explain

.

Please be advised that we have access to doctors

who are qualified for expert MedicoLegal testimony.

NOTE: ALL REPORTS REQUESTS FROM PUBLIC AND

PRIVATE AGENCIES MUST BE PROCEEDED BY A

FOLLOW UP INTERVIEW AT YOUR COST. INITIALING

HERE INDICATES UNDERSTANDING OF THIS SECTION.

Patient Initials:

Use this space for anything else you think the

doctor should be aware of:

Thank you for your time and interest in answering

all of these questions. Your answers will be very helpful

for future research on the subject, and will make the

doctors job much easier in determining eligibility.

Fill this form out while on-line and either print it out,

or save it to a file on your system that will print out the

questionnaire with the filled out answers. Then you can

take a copy to your appointment for a doctor to review.

Return Back To Main Medical Page