PATIENT PRE-QUALIFICATION FOR THE MICHIGAN MEDICAL MARIJUANA PROGRAM
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1 Appt. Time: Date: NEW RENEWAL Cost of Service: $ PAID WITH: CASH Service : PURE WEST 840 N Black River Dr Suite 90 Holland, MI purewestclub@gmail.com PATIENT GENERAL INFORMATION $125 $150 $175 Location: HOLLAND OFFICE NOTES: CK IN Pre-Registration : $25 QUE CK CK OUT First Name: Address: Middle Initial: Apt #: Last Name: Date Of Birth: City: State: Zip: Sex: Male Female DL: Phone No.: Are you a Veteran? Yes No Emergency Contact: Name: Phone No. How did you hear about PURE WEST (please be specific). Google Search Leafly Get Legal America Weed Maps Other: Marijuana Doctors.com MMMP Report ATIENT PRE-QUALIFICATION FOR THE MICHIGAN MEDICAL MARIJUANA PROGRAM Is Is this CERTIFICATION with MMMP: NEW or RECERTIFICATION Will you have a caregiver? Yes No If yes, provide First Name Middle Initial: Last Name D.O.B Address: Apt#: City: State: Zip: Phone No: Sex: Male Female PATIENT PRE-QUALIFICATION FOR THE MICHIGAN MEDICAL MARIJUANA PROGRAM The following conditions are qualifications for the MMMP program. Please select the condition(s) you are seeking qualifications for the MMMP program. Amyotrophic Lateral Sclerosis: Agitation of Alzheimer s: Arthritis: Cachexia Disease: Crohn s Disease: Cancer: Glaucoma: HIV/AIDS: Multiple Sclerosis: Nail Patella: Muscle spasms: Persistent Migraines: Severe Nausea: Seizures: Chronic Pain: Severe Pain: Hepatitis C: Post-Traumatic Stress Disorder: Other 1
2 Hospitalizations? Surgeries? Previous counseling? With Whom? When? Suicidal Ideation? Sleep or Appetite Problems? Serious Accidents? Infectious Diseases? If Yes, Please describe Allergies or Adverse Reactions? If Yes, Please Describe How Long Have You Been Experiencing Your Symptoms? How Long Have You Been Receiving Treatment for this Condition? Do you smoke Marijuana? Yes [ ] No [ ] Has Marijuana helped with your condition? Yes [ ] No [ ] Explain your Marijuana use and results Are You Allergic to Any Medications? If Yes Do You Currently Take Prescription Medication? Yes [ ] No[ ] Please List ALL Medications that you are currently taking. If You Already Have a List Prepared, You May Leave This Area Blank And Submit Your List To The Doctor. Name of Medication Dosage Condition Used For What is the name and address (city is fine) of the doctor(s) that you have seen for the condition(s)? I Hereby Certify That All The Information That I Have Provided On This For Is True And Accurate Signature Date
3 Patient Name: Date of Birth: General: Mark if you have had any of the following in the past 3 months Fever Chills Night Sweats Nausea or vomiting Weight Gain Weight Loss Marked Fatigue Dizziness Chest Pain Difficulty Breathing Social History Smoker Other tobacco products Street Drugs (Other than Marijuana, strictly confidential) Alcohol Daily Weekly Please mark diseases, symptoms or other items corresponding to your current and past health Problems: Eyes, Ears, Nose, Throat Gastrointestinal Glaucoma Chronic Constipation Cataracts Chronic Diarrhea Hearing Loss Left Right Both GERD Frequent Ear Infections Ulcers Seasonal Allergies Heartburn Sinus Problems Crohn s Difficulty Swallowing Colitis Eye Pain Cachexia or Wasting Syndrome Other Persistent Nausea Frequent Vomiting Blood in Stool Cardiovascular Decreased Appetite Diverticulitis High Blood Pressure Other High Cholesterol Heart Attack Angina Nervous System Cardiac Arrhythmias Migraine or other Headaches Palpitations Nerve pain or Neuropathy Pace Maker Insomnia / Sleeping Disorder Stroke (Lasting deficits) Parkinson s Disease TIA (Symptoms resolved completely) Post Herpetic Neuralgia (Shingles pain) Peripheral Vascular Disease Head Injury Other Multiple Sclerosis Epilepsy/Seizures Respiratory Severe and Chronic Pain Other Asthma COPD Emphysema Renal Chronic Bronchitis Kidney Disease Pulmonary Embolism Require Dialysis DVT (Blood Clot) Other Lung Problems Frequent Kidney Stones Other Integumentary Psoriasis Photosensitivity Skin Cancer Other Skin Problems Infectious Disease HIV/AIDS Hepatitis A B C Tuberculosis Valley Fever Other
4 Cancers Cancer : Type Cancer: Type Family History of Cancer diagnosed before age 50 yrs ***Are you currently or previously Treated with: Chemotherapy Started: Duration: Treatments Per Week: End: Radiation Therapy Body Part: Start: Duration: End: Metabolic/Endocrine Diabetes Type I or II (circle one) Thyroid Disorder Anemia Obesity Polycystic Ovarian Syndrome (PCOS) Metabolic Syndrome Other: Musculoskeletal Severe and Persistent Muscle Spasms Osteoarthritis Osteoporosis Broken Bone: Where: Degenerative Disk Disease Rheumatoid Arthritis Other Arthritis Fibromyalgia Joint Pain Muscle Pain B one Pain Amyotrophic Lateral Sclerosis Other Surgeries Tonsillectomy Appendectomy Back Surgery Other bone/joint surgery Procedure to decrease pain: Injections to treat painful areas Transplant Surgery Abdominal Surgeries Heart Surgery Other Surgery or Procedure Mental Health Panic Disorder Depression Anxiety Bipolar Disorder Schizophrenia Alzheimer s Disease Dementia Obsessive-compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) ADD/ADHD Suicidal thoughts, plans, or attempts History of abuse History of drug abuse Other THIS SECTION FOR WOMEN ONLY: Could you be pregnant: YES NO Taking hormones Using oral contraceptive Pelvic Inflammation Disease Hysterectomy Full Partial Date: Ovaries Removed Date: Heavy Periods PMS or PMDD Trying to get pregnant YES NO Currently taking bi rth control Decreased Libido Hot Flashes Tubal Ligation Date: Natural Post Menopause Date of Last Period: Irregular Periods Other THIS SECTION FOR MEN ONLY Problems Urinating Decreased Erectile Libido Dysfunction Prostate Enlargement Problems Urinating Erectile Dysfunction Other I certify that the above information is true and accurate to the best of my ability. Signature (Required) Date:
5 No marijuana-related legal action pending Agreement By signing below, I,, assert that as of today, the day of in the year, I have NO marijuana-related legal issues pending in the courts of any level of government. Examples of pending marijuana-related legal issues include, but are not limited to: unresolved misdemeanor or felony criminal charges stemming from the growing, possessing or operating a vehicle under the influence of marijuana, probation violation hearings concerning testing positive for marijuana activity (medical or otherwise) and civil actions against employers or former employers concerning termination of employment relating to your status as a medical marijuana patient. I understand that according to the Michigan Medical Marihuana Act s affirmative defense outlined in MCL (a)(1), a bona-fide patient-doctor relationship must be established by any defendant/patient who seeks to have his criminal charges successfully dismissed under the MMMA. I understand and agree that breaching this agreement will render null and void any bona-fide patient-doctor relationship that may have existed between myself and the physicians at Pure West Compassion Clinic at the time of service. I also further assert that any and all information I give pertaining to my qualifying condition as defined by the State of Michigan, is accurate and complete. I further understand that should an applicable court refuse to dismiss a pending criminal charge as a result of the contents of this agreement, I will hold Pure West Compassion Clinic harmless for the legal consequences associated with my potential sentence, incarceration, civil forfeiture, fines, restitution, court and attorney costs. This agreement pertains to treatment and services provided by Pure West Compassion Clinic a Michigan Corporation. Signature of Patient Date Signature of Witness Date Pure West Compassion Clinic
6 Physician Release from all Liability Form Signing this form releases the physicians of Pure West Club from all liability for providing a state of Michigan medical marijuana Physician s Certification. And by signing this form, you, the patient-applicant, are stating that you understand and agree with the following statements of fact: 1. The federal Food and Drug Administration approves all drugs prescribed by physicians. Medical Marijuana is not an FDA approved medication. Crude marijuana is not standardized regarding its purity, strength or dosage size. 2. Therefore, the physicians of Pure West Club cannot write a prescription for medical marijuana and has no control over the ingredients or the effects or the adverse risks of whatever medical cannabis you decide to consume nor can they, in any way, help or tell you how to acquire or grow it. Please consult the internet or your local compassion club. 3. The physicians of Pure West Club may not be able to provide you with thoroughly researched conclusions regarding all the potential benefits and adverse risks of cannabis use for your particular qualifying medical condition. The scientific research on cannabis is incomplete and does not meet the high requirements for all other medicines approved by the FDA. 4. The physicians of Pure West Club cannot provide you with a regimen for the use of medical marijuana. You are solely responsible for administering medical marijuana as your condition warrants, as determined on the basis of your own judgment and are solely responsible for all the consequences. 5. Please take care if you have not used marijuana before. You are advised to keep a log of how much medicine you use and its effects on your symptoms. This will help you make adjustments to your dose and frequency. 6. You are in charge of the most comfortable and effective method of delivery vaporizer, topical, smoking or edibles. (It is not advisable for patients with lung issues or smoke allergies to smoke marijuana.) These are general guidelines and should be used in conjunction with your own common sense and wisdom about your health. 7. The cultivation, possession and use of cannabis even for medical purposes remains a crime under federal law. 8. Medical marijuana is generally tolerated well by patients. Any side effects tend to be mild and temporary, usually lasting one week or less as patients adjust. Common side effects include irritated throat, dry mouth, elevated heart rate, mild time and space disorientation, mild euphoria, a general sense of well-being, and in some instances drowsiness and a motivation. I,, agree not to make any legal claim or complaint, or commence any proceeding against Pure West Compassion Clinic. in providing me with a Physician s Certification as required by the Michigan Medical Marijuana Act. And I further agree not to make any legal claim or complaint or commence any proceeding against the same physician for my use of crude medical marijuana. I release the same physician from any and all actions, causes of actions, claims, complaints and demands for damages, loss of injury whatsoever arising directly or indirectly as a result of my medical marijuana application to the state of Michigan or my use of medical marijuana. This release of liability is to be binding on my heirs, executors and assigns. I have read, understand and agree with all the statements in this form. Signature of applicant Date Signature of witness Date
7 Your Follow Up Care Please call us within 30 days to inform us how the program is working for you. As always, our business staff is available 5 days a week to answer any questions you may have. You can also us at purewestclinic@gmail.com. We expect to provide follow-up care to you to monitor the efficacy of your medical use of marijuana. As of April 1, 2013, the state is issuing two-year cards. However court cases in Michigan have held that a registry card even one verified by the state-does not prove ongoing contact between the physician and patient. For your protection, Pure West Compassion Clinic will need an annual appointment with you to maintain your doctor-patient relationship as required by the state. The charge for this annual appointment next year will be $79. We will review and assess your medical history and current medical conditions to determine that you are still likely to receive therapeutic or palliative benefit from the medical use of marijuana to treat your condition. We will also discuss how well the program is working for you and offer recommendations for any additional care, such as alternative therapy. Patient Name (please print) Patient signature Date of birth Today s Date THE PHYSICIAN MUST INITIAL EACH LINE BELOW: I do hereby declare that the written certificate was prepared in the course of a bona fide physician-patient relationship in which each of the following were present as part of the treatment or counseling relationship: I have reviewed this patient s relevant medical records and completed a full assessment of this patient s medical history and current medical condition, including a relevant, in-person, medical evaluation of this patient. (MCL (a)(1)) I have created and will maintain records of this patient s condition in accord with medically accepted standards.(mcl (a)(2)) I have a reasonable expectation that I will provide follow-up care to this patient to monitor the efficacy of the use of medical marihuana as a treatment of this patient s debilitating medical condition. (MCL (a)(3)) If the patient (or for minor: parent/legal guardian) has given permission, I have notified this patient s Primary care physician of this patient s debilitating medical condition and certification for the use of medical marihuana to treat that condition(mcl (a)(4))
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DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
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The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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stoneburner acupuncture
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Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State:
Health Profile. Last Name: First Name: Address: Apt/Unit: # City: State: Zip/Postal Code: Phone: Cell:
1 Health Profile Date: / / / Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order
PATIENT REGISTRATION FORM
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Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
PATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
FAMILY MEDICINE New Patient Medical History Form
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Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
Kimberly L. Limbo, MD Kellie D. Anderson, CRNP Dear Parent, Thank you for choosing Huntsville Hospital Pediatric Neurology for your child s medical care. Our website should help answer any questions about
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
Highland Colony Dental- Donald K. Givan, DMD
Highland Colony Dental- Donald K. Givan, DMD ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRAcTICES *You May Refuse to Sign This Acknowledgement* I, have received a copy of this office s Notice of Privacy
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PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
HEADACHE HISTORY FORM
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New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):
HD CLINIC MEDICAL HISTORY FORM
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PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
Patient Intake Sheet
Patient Intake Sheet Patient Information Name: Cell Phone: ( ) Address: Work Phone: ( ) Emergency Phone: ( ) Email Address: Date of Birth: Age: Who referred you? Weight: Height: Who is your primary care
Health History Intake Form;
Health History Intake Form; Today s Date: Patient Name: Date of Birth: Age: Previous Primary Care Physician (if any): Phone: Address: Other Physicians involved in your care: Reason for visit today: Allergies
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 QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic