Patient Information:First Name *Last Name *Phone *Email *Birth Date *mm/dd/yyyyGender *MaleFemaleAddress *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryWhere did you hear about us? Medical HistoryDo you have or have you ever had any of the following conditions/illnesses/problems? *Allergies/AsthmaAnxietyArthritisCancerCirculatory problemsDepressionDiabetesDizzinessElimination problemsFatigueHeadachesHeart conditionHigh blood pressureLow blood pressureInfectious diseaseInsomniaMuscular Injuries/DiseaseNeurological problemsPregnancyReproductive problemsRespiratory ProblemsSkin disordersSpinal/Skeletal problemsStrokeOtherNoneIf other, please list For what condition do you seek medical marijuana? * Marijuana History:Do 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)TopicalsOtherDoes marijuana provide relief for your symptoms YesNoIf yes, please describe How effective is marijuana in treating the symptoms of your condition? Very effectiveEffectiveSomewhat effectiveNot effectiveHow does marijuana compare with your usual prescribed medicines in relieving your symptoms? Prescribed 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 togetherFrequency of marijuana use as medicine (i.e. daily, weekly, monthly etc.) Have you had any negative/adverse reaction from use of marijuana? YesNoIf yes, please describe Additional Information that you consider relevant to physicians evaluation: This information will be used to help create a recommendation that can be used as a guide to help provide information on what types and delivery methods would be most appropriate to help treat the certifying condition. It is only a recommendation and in no way replaces your doctors advice. The content of this form is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health providers with any questions you may have regarding a medical condition. CaregivingDo you currently need a caregiver to help you with your medical marijuana needs? *YesNoAre you or someone you know interested in becoming a caregiver? *YesNo SignatureDigital Signature *I understand that typing my full name constitutes a legal signature confirming that I acknowledge and agree all above information is accurate and truthful.Today's Date * VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
