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