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6/6/2019 Lotus Health LLC Follow Up/Progress Communication: Complete Upon Receipt 

The providers at Lotus Health LLC would like to know about your progress. Please answer all questions to the best of your ability. As always, feel free to email Teaera, Dr. Short, Dr. Goldenberg, or Dr. Pope directly with any questions you may have regarding your treatment plan. For dispensary information, please direct yourself to the Ohio Medical Marijuana Control Program website. You can also utilize Weedmaps.com or Leafly.com for a map of the dispensary locations.
HB523 indicates we must report non patient specific information pertaining to the health outcomes of our clients. Please make sure this form is filled out and sent back to us in the mail or electronically.
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1.Last Name

(Required.)
2.First Name

(Required.)
3.Age:

(Required.)
4.Do you have a registered caregiver?

(Required.)
5.Please indicate the Ohio qualifying diagnosis you are attempting to treat with medical cannabis: (Only include the diagnosis in which you have actually been diagnosed by a certified medical professional legally able to diagnose). Please mark all that apply:

(Required.)
6.Please indicate if you have been able to utilize an Ohio Medical Marijuana Dispensary:

(Required.)
7.If you have not utilized and Ohio Dispensary, please indicate the reason:

(Required.)
8.Have you been able to treat your ailment with any amount of success?

(Required.)
9.Have you been able to decrease or stop any medications you were taking prior to starting medical cannabis to treat/prevent your ailment?

(Required.)
10.If you have decreased or discontinued traditional medication, indicate the type(s) of medications.

(Required.)
11.Do you currently supplement with any cannabinoid products such as CBD oil?

(Required.)
12.Do you feel as though cannabis has increased your overall quality of life?

(Required.)
13.Have you communicated your current or planned cannabis use with your current healthcare providers?

(Required.)
14.If you have communicated your health plans with cannabis, what was the outcome?

(Required.)
15.Which route(s) of administration do you use or plan to use once available?

(Required.)