Patient InformationFirst Name *Last Name *Phone *Email Address *Birth Date *Gender (Biological) *MaleFemaleStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Where did you hear about us?Medical HistoryDo you have or have you ever had any of the following conditions/illnesses/problems? (Check all that apply) *Allergies/AsthmaAnxietyArthritisBipolar DisorderCancerCirculatory problemsDepressionDiabetesDizzinessElimination problemsFatigueHeadachesHeart conditionHigh blood pressureLow blood pressureInfectious diseaseInsomniaMuscular Injuries/DiseaseNeurological problemsPregnancyReproductive problemsRespiratory ProblemsSchizophreniaSkin disordersSpinal/Skeletal problemsStrokeOtherNone of the aboveIf other, please list *For what condition do you seek medical marijuana? *Marijuana HistoryDo you presently use marijuana to treat your medical condition? *YesNoIf yes, for what condition do you use marijuana? *Method of marijuana use as a medicine *VaporizeEdiblesSmoke/BurnOral (tincture/sublingual)TopicalsOtherHow effective is marijuana in treating the symptoms of your condition? *Very effectiveEffectiveSomewhat effectiveNot effectiveDoes marijuana provide some relief for your symptoms? *YesNoIf yes, please describe *How does marijuana compare with your usual prescribed medicines in relieving your symptoms? *I do not/have not taken prescribed medicine for my conditionPrescribed medicines work much betterPrescribed medicines work a little betterPrescribed medicines work the same as MarijuanaMarijuana works a little better than prescribed medicinesMarijuana works much better than prescribed medicinesMarijuana and prescribed medicines work best togetherHave you had any negative/adverse reaction from use of marijuana?YesNoIf yes, please describe *Frequency of marijuana use as medicine (i.e. daily, weekly, monthly etc.) *Additional Information that you consider relevant to physicians evaluationCaregivingDo you currently need a caregiver to help you with your medical marijuana needs? *YesNoAre you or someone you know interested in becoming a caregiver? *YesNoMaybeSignature I understand that typing my full name constitutes a legal signature confirming that I acknowledge and agree all above information is accurate and truthful.Digital Signature *Date *Submit Form