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

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

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

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

Explain:

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 preference other, if other specify,

List "street name" varieties strain names used that have helped you.

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

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?

increasedecreasedno 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 condition/

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 discontinued 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 attitudeto 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

discontinuing, cost of medication per month.

Non-medical psychoactive drugs, include: Alcohol,

drinks per week, Tobacco:Cigarettes per day,

Cocaine/Amphetamine:times per month, Heroin 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 discussed 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 Medico Legal 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.

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