Southwest Medical Marijuana Evaluation Center
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- James Osborne
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1 Personal Information: Southwest Medical Marijuana Evaluation Center Health Questionnaire Date Name Date of Birth Age Height: Weight: Gender: Male / Female Address City State/Zip Best Contact #: Address: Occupation: FEMALES ONLY: CURRENTLY PREGNANT? Y / N Medical History Current medical concern: (List the medical problem(s) for which you use or, would like to use medical marijuana; include year of onset of symptoms) Treatments: check any treatments you use / have used for your condition: Surgery physical therapy chiropractic massage herbal therapy counseling exercise acupuncture: other Primary Care Provider: Please give the name & address of your healthcare provider (includes chiropractor/psychologist/acupuncturist etc.) Please also list the date you were last seen by that provider; Prescription Medications: include the strength and dosing instructions Non Prescription and Supplements: Allergies to medications / indicate what the allergy causes, eg. Hives, rash, nausea etc) Hospitalization / Surgical History: list any hospitalizations / surgeries that you have had (include dates): Social History : Do you currently use: Tobacco Yes/ No # of cigarettes per day Alcohol Yes/ No # of drinks per week Exercise 3-5x/wk Yes/No Family History: Do your parents, siblings or children have/had any significant medical/psychological problems? Yes No If yes, please explain: Page 1 of 7
2 Review of Systems Do you have or have you ever had any of the following medical problem? Asthma/Lung Disease Cancer HIV/AIDS Diabetes Hepatitis Epilepsy/Seizures Stroke Liver Disease Kidney Disease High Blood Pressure Heart Disease Sleep Disorders Substance Abuse Intestinal Disorders (IBS, Ulcers) Psychiatric Disorders NORMAL check if ABNORMAL General fever chills night sweats fatigue wt change appetite change insomnia Head/Face sinus pain sinus drainage facial pain Ears earache ear discharge decreased hearing tinnitus Eyes eye pain red eye blurred vision double vision eye discharge Oral Cavity sore throat swallowing difficulty toothache gum swelling Hoarseness Skin rash itching bites sores redness acne bruising varicose veins CV chest pain palpitation edema anemia Resp cough breathlessness wheezing sputum bloody sputum GI Pain nausea vomiting bloody vomiting diarrhea bloody/dark stools mucus stools Gas/bloat indigestion MusculoSkeletal joint pain joint swelling redness limited movement leg cramps Pain Scale today: None severe (circle #) CNS headache migraines weakness numbness tingling poor Genitourinary balance/coord frequency urgency burning bloody urine discharge (females only) irreg periods currently pregnant breastfeeding Psych mood interest concentration sleep problems Suicidal ideation anxiety SCHIZOPHRENIA Explain any abnormals indicated from above: Page 2 of 7
3 Activities of Daily Living Assessment Rate your current difficulties by placing the appropriate number in the box. If an activity does not cause pain or if pain does not affect an activity, leave box blank. [ 1 ] This activity causes some pain, but it is only a minor annoyance. [ 2 ] This activity causes a significant amount of pain, but I can do it. [ 3 ] I cannot perform this activity due to pain and disability. Self Care and Personal Hygiene [ ] bathing/showering [ ] brushing teeth [ ] putting on shoes [ ] eating [ ] doing laundry [ ] grooming hair [ ] making the bed [ ] putting on pants [ ] dishes [ ] going to toilet [ ] washing face [ ] putting on shirt [ ] cooking [ ] taking out trash Physical Activities [ ] standing [ ] walking [ ] reaching [ ] bending right [ ] twisting right [ ] sitting [ ] squatting [ ] bending forward [ ] bending left [ ] twisting left [ ] reclining [ ] kneeling [ ] bending back [ ] looking left [ ] looking right Functional Activities [ ] carrying small objects [ ] lifting weights off table [ ] pushing/pulling while standing [ ] carrying large objects [ ] climbing stairs/incline [ ] exercising upper body [ ] carrying briefcase/purse [ ] pushing/pulling while seated [ ] exercising lower body [ ] lifting object off floor Social and Recreational Activities [ ] bowling [ ] jogging [ ] swimming [ ] golfing [ ] dancing [ ] biking [ ] hunting/fishing [ ] competitive sports [ ] gardening [ ] walking [ ] horse riding [ ] other: Difficulties with Traveling [ ] driving in car [ ] driving for long periods of time [ ] riding as passenger [ ] riding as passenger for long periods of time I certify that the above responses are complete and accurate to the best of my knowledge: _ Physician s Signature: Page 3 of 7
4 Medical Marijuana (MMJ) History Have you been evaluated by another physician (in any state) for MMJ? Yes / No If yes, list the name of the practice, doctor, and date seen: Do you use MMJ to reduce or eliminate the use of any medications that have been prescribed for your medical condition? Yes/No If yes, which medication have you reduced or eliminated and why? How often do you use MMJ? ( ) x day ( ) x/ week ( ) x/month What is your preferred method of using MMJ? ( ) smoke ( ) vaporizer ( ) ingested ( ) topical ( ) tincture How effective is MMJ for your medical problem? ( ) very effective ( ) effective ( ) only somewhat effective How does MMJ improve the quality of your life? Additional Information Do you have an open court case regarding marijuana? Yes / No Are you currently on probation? Yes / No Please provide any additional information that may be relevant for your physician to know: I understand that the information I have been asked to provide is for the diagnosis and treatment of the medical condition for which I am seeing the physician today and, if I have not accurately and completely disclosed the requested information, it may adversely impact the physician s ability to diagnose my condition and recommend appropriate treatment. I certify that the information in this questionnaire is accurate and complete and has been offered only for the purpose of gaining treatment of my medical condition. I further certify that I am not seeking marijuana for illegal purposes; I am not a reporter or member of the media working on a story; And, I am not a member of law enforcement seeking to investigate or build a case against my physician or anyone affiliated with my physician. Date Print Name Page 4 of 7
5 I understand that: [please initial each item] Southwest Medical Marijuana Evaluation Center PATIENT ACKNOWLEDGEMENT The attending physician, staff and or representatives of Southwest Medical Marijuana Evaluation Centers (herein SWMMEC) are neither providing, dispensing nor encouraging me to obtain medical marijuana. The attending physician, staff and or representatives of SWMMEC will NOT be providing or discussing information regarding dispensary, co-op, delivery service or any other way to obtain marijuana. The physician, staff and representatives of SWMMEC are addressing specific aspects of my medical care and, unless otherwise stated, are in no way establishing themselves as my primary care physician/provider. Should an approval be made for my medicinal use of cannabis, there is a renewal date specified by the state. It is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval. I acknowledge that I am a resident of Arizona, I am at least 18 years of age and have not misrepresented any information to SWMMEC. I acknowledge that I am not an agent of law enforcement, state or federal government here for the purpose of investigation or entrapment. I acknowledge that I am not recording any portion of my visit with SWMMEC nor do I possess any recording equipment. I understand SWMMEC does not approve of such action. I further acknowledge that, without express written permission of SWMMEC, it is illegal to film or record in this office with video camera, cell phone or any other recording devices, including still image, video or audio. Any such action is a direct violation of HIPAA regulations and patient/ doctor confidentiality. I acknowledge that it is up to me to become a patient of SWMMEC and am in no way being coerced to do so. I acknowledge that marijuana, even if used for medical purposes, is illegal under Federal law and has been placed on Schedule 1 by the US FDA. As such, marijuana is considered to have no medical benefit and a significant potential for abuse. I assume all responsibility for any violation of Federal law. Date Print Name Page 5 of 7
6 INFORMED CONSENT AND RELEASE FROM LIABILITY I am being evaluated for a physician s recommendation for medical marijuana. The physician will make this recommendation based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non-medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of marijuana. I have been informed of and understand the following: [please initial each item] I must be an Arizona resident and over the 18 years of age to obtain an approval or recommendation for the use of cannabis (medical marijuana) under Arizona law. If I am under 18 years of age I must have parental consent and authorization for the use of medical marijuana. The federal government has classified marijuana as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (1) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states, such as Arizona, which have modified their state laws to treat marijuana as a medicine. Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore the manufacture of marijuana for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients (i.e., can vary in potency), impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana. The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly. I understand that if I drive while under the influence of marijuana, I can be arrested for driving under the influence. Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short-term memory, euphoria, difficulty in completing complex tasks, suppression of the body s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of marijuana may increase eating, alter my perception of time and space and impair my judgment. I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana. I agree to contact a physician/emergency medical facility if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact a physician/emergency medical facility if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends. Smoking marijuana may cause respiratory problems and harm, including bronchitis, emphysema and laryngitis. In the opinion of many researchers, marijuana smoke contains known carcinogens (chemicals that can cause cancer) and smoking marijuana may increase the risk of respiratory diseases and cancers in the lung, Page 6 of 7
7 mouth and tongue. In addition, marijuana smoke contains harmful chemicals known as tars. If I begin to experience respiratory problems when using marijuana, I will stop using it and report my symptoms to a physician. It is the recommendation of the physicians at SWMMEC to not smoke medical marijuana. Safer, less harmful methods of administration include; ingesting (edible), vaporizing and or tinctures. The risks, benefits and drug interactions of marijuana are not fully understood. If I am taking medication or undergoing treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s). Individuals may develop a tolerance to, and/or dependence on, marijuana. I understand that if I require increasingly higher doses to achieve the same benefit I could be developing a dependency on marijuana, and should seek medical assistance. Signs of withdrawal can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness. Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to go to the nearest emergency room. If SWMMEC subsequently learns that the information I have furnished is false or misleading, the recommendation for marijuana may no longer be valid. I agree to promptly meet with SWMMEC and/or provide additional information in the event of any inaccuracies or misstatements in the information I have provided. I have had the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge the SWMMEC physician informed me of the nature of a recommended treatment, including but not limited to, recommendations regarding medical marijuana. The SWMMEC physician also informed me of the risks, complications and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge the SWMMEC physician informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits. Furthermore, I, the undersigned (including my heirs, or anyone acting on my behalf), hold SWMMEC, the physician and his/her principals, agents, employees and management, harmless and release them from any liability resulting in any way whatsoever from my use of marijuana. This release of liability includes, but is not limited to, any bodily or psychological injury, whether known or unknown, as well as legal and/or employment problems resulting from my use of marijuana. Date Print Name Page 7 of 7
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GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
Welcome to MedWell. MedWell Health and Wellness Centers. Don t live with PAIN Live WELL MedWell. o Newspaper o Referred by.
1 Welcome to MedWell Patient Information Date: Name: Date of Birth: / / Address: City: State: Zip Code: Home Phone: ( ) - Cell Phone: ( ) - Email: Gender: o Male o Female State Drivers License: Social
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
Medical Information. (office use) MRN: CMRN: Last Name: First Name: Middle Initial: Date of birth: Age: Sex: M F Height: Weight:
1835 W. County Rd C, Suite 80, Roseville, MN 55113 P: 651-797-6880 F: 651-797-6881 info@spartzvein.com spartzvein.com Medical Information Date of consultation: (office use) MRN: CMRN: Last Name: First
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Patient Registration Form
Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip:
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY (859) General Information
Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY 40517 (859) 268-8190 General Information Full Name Birth date / / Date / / Social Security # - - Driver s License
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Ethnicity: Hispanic Non-Hispanic Mr. Mrs. Ms. Miss Is this your legal name? If not, what is your legal
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM
Name: MR#: Date: DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM Referring Physician s Name: Primary Care Provider s Name: 1. What was/were your first movement disorder symptoms? What did you
Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon