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  • Home
  • Get Your Card
    • Apply for your PA Medical Marijuana Card
    • Schedule a Comprehensive Consultation
    • Financial Assistance Program
    • ID Upload
  • Get the App
  • Education
    • Qualifying Medical Conditions for PA
    • Getting Your PA Medical Marijuana Card
    • PA Medical Marijuana Caregiver Card
  • About
    • About The Greener Institute
    • Reviews and Testimonials
    • FAQs
    • Our Process
  • Blog
  • Contact

Patient Medical History Intake Form


Patient Information

Gender (Biological) *

Medical History

Do you have or have you ever had any of the following conditions/illnesses/problems? (Check all that apply) *

Marijuana History

Do you presently use marijuana to treat your medical condition? *

Method of marijuana use as a medicine *

How effective is marijuana in treating the symptoms of your condition? *
Does marijuana provide some relief for your symptoms? *
How does marijuana compare with your usual prescribed medicines in relieving your symptoms? *
Have you had any negative/adverse reaction from use of marijuana?

Caregiving

Do you currently need a caregiver to help you with your medical marijuana needs? *
Are you or someone you know interested in becoming a caregiver? *

Signature

Medical Marijuana Cards Here!

If you are looking for Medical Marijuana Cards and/or Caregiver Cards, we can help! Contact us now to learn more.

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