Medical History Question Title * 1. Name (First, Middle, Last): Question Title * 2. Birthday: Question Title * 3. Email: Question Title * 4. Phone: Question Title * 5. Address: Question Title * 6. Referred by: Question Title * 7. Primary Care Provider: Question Title * 8. Specialty Care Provider (i.e. neurologist; oncologist; psychologist): Question Title * 9. Preexisting Qualifying Condition: (Please select all that apply.) Cancer Glaucoma HIV/AIDS Severe Pain Seizure or Epilepsy PTSD Catchexa or Wasting Syndrome Severe Nausea Severe Persistant Muscle Spasms, MS, Chrons Disease Question Title * 10. Medical History: (Please select all that apply.) Diabetes Hypertension Migraines Arthritis Back Pain Depression Anxiety Mood Disorder Insomnia Fibromyalgia Neuropathy Scoliosis endometriosis/Menstral Cramps Other (please specify) Question Title * 11. Surgeries/Accidents: Question Title * 12. Allergies: Question Title * 13. Medications: (Please select all that apply.) Tylenol Ibuprofen Neurontin Glucophage Lyrica Cymbalta Lisinopril Metformin Narco Hydrocodone OxyContin Alprazolam Clonazepam Lorazepam Question Title * 14. List other Medications: Question Title * 15. Alternative Care Providers/Therapies: (Please select all that apply.) Physical Therapy Chiropractor Acupuncture Massage Naturopath Other (please specify) Question Title * 16. Any Other Health Related Information: Question Title * 17. Will you be applying for a Care Taker Certificate: If YES, please upload your Caretaker ID and Signed forms to the Dept of Health Website. Yes No Question Title * 18. Will you be applying for a grow-site: If YES, please upload your Marked and Signed forms to the Dept of Health Website. Yes No Question Title * 19. Do you have any other comments, questions, or concerns? Question Title * 20. Patient Electronic Signature: Question Title * 21. Provider Signature and verification of Information Provided: Done