Welcome to MedWell. Patient Information. Name: Address: City: State: Zip Code: !Other. Name: Address: City: State:

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1 1 Welcome to MedWell Patient Information Date: Name: Date of Birth: / / Address: City: State: Zip Code: Home Phone: ( ) - Cell Phone: ( ) - Gender:! Male! Female Last 4 of Social Security Number : How did you hear about MedWell:! Instagram! Facebook! Google! Recertification!Referred by!other Your Primary care physician information Name: Address: City: State: Have you had a medical marijuana recommendation from a doctor before?! Yes! No Page 1 of 5

2 2 If yes, please provide name of physician and/or practice Past Medical History! HIV/AIDS! Weight Loss/Gain! MS! Crohns Disease / Ulcerative Colitis! Hepatitis C! Anorexia! Seizures! Insomnia! Arthritis! Nausea / Vomiting! IBS! Alzheimer s Disease / Education! Cancer!Chronic Pain! Depression! Diabetes! Glaucoma! Neuropathy! Anxiety! High Blood Pressure! Migraine HAS! COPD / Asthma! Fibromyalgia! Other Past Surgical History Please list any surgeries that you have had in the past. Include the reason, date, hospital and doctor who performed the surgery. Review of Symptoms: General Gastrointestinal Muscle/Joint/Bone/Pain! Anxiety! Abdominal pain or cramps! Neck! Legs! Chronic Pain! Bowel changes! Shoulder! Knees! Dizziness! Nausea! Back! Ankles! Headache! Poor Appetite! Arms! Feet! Loss of Sleep! Vomiting! Hands! Arthritis! Loss of weight! Hips! Muscle Cramps Psychiatric Cardiovascular Neurological Page 2 of 5

3 3! Anxiety! Cardiac Palpitations! Fainting! Depression! High Blood Pressure! Headache! Disturbing feelings! Irregular heartbeat! Numbness! Panic Attack! Rapid Heartbeat! Seizures! Restlessness! Neuropathy Current Conditions! Aids! Alcoholism Chemical Dependency! Anorexia! Anxiety! Arthritis! Cancer! Chemical Dependency! Chronic Pain! HIV Positive! Depression! Epilepsy! Fibromyalgia! Glaucoma! Insomnia! Migraine Headaches Others: Medications Over the counter Prescribed Chief Complaint Please describe the medical condition(s) or complaints that you are seeking a recommendation for medical marijuana. (How long have you had symptoms/diagnosis?) Does this medical condition limit your ability to conduct major life activities? (Work, Eat, Sleep, Interact with others)! Yes! No Do you feel that if this medical condition is not alleviated, it may cause serious harm to your physical or mental health, and safety?! Yes! No Page 3 of 5

4 4 Have you received medical care or evaluation by a physician/specialist for this medical condition?! Yes! No If yes, please provide the name, address and date last seen by the physician (including chiropractor/acupuncture) that diagnosed and/or treated you for this medical condition/s: If not listed, please describe all treatments that you have received to date for your current medical problems such as the medications prescribed, surgeries, physical therapy, acupuncture, homeopathy, or chiropractic care: Do you currently smoke cigarettes?! Yes! No Do you currently drink alcohol?! Yes! No Do you have history of illicit drug use?! Yes! No Are you currently using any opioids?! Yes! No Are you Currently Pregnant or nursing?! Yes! No Cannabis (Marijuana) History Do you currently use cannabis to treat your current medical condition?! Yes! No At what age did you discover that cannabis eased your symptoms? Does cannabis provide relief for your symptoms?! Yes! No If yes, please describe. (Example; less pain or nausea) How often do you use marijuana:! Daily! Weekly! Monthly Page 4 of 5

5 5 How much cannabis do you consume per treatment? What method do you currently use to consume the cannabis? (Please check all that apply)! Vaporize! Ingest/edible! Smoke! Anointing oil Additional Information Please provide any other information you believe is relevant to the doctor s evaluation: Patient Signature Date / / Page 5 of 5

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