PATIENT QUESTIONNAIRE
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- Carmella Ellis
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1 PATIENT QUESTIONNAIRE Personal Information Date Name Date of Birth Age Height Weight Gender: Male / Female Address City State / Zip Home Phone Cell phone Work phone address Do you currently have Medical Insurance? Yes /MediCal No If yes, circle what kind: Private /Medicare Medical History Current Medical complaint: (List the medical problems for which you use or would like to use Medical Marijuana; include year of onset of symptoms.) Primary Care Provider: Please give the name and address of your health care provider (includes Chiropractor, Psychologist/Acupuncture, etc.) Please also list the date you were last seen. Medications: List all of your medications (include prescriptions and over-the-counter) List any medications that you are allergic to: Other treatments: Check any other treatments you use for your condition: Surgery Physical Therapy Chiropractic Massage Herbal Therapy Counseling Exercise Other
2 Medical History (continued) Do you have or have you ever had any of the following medical problems? Asthma/Lung Disease HIV/AIDS Hepatitis Stroke Kidney Disease Heart Disease Substance Abuse Multiple Sclerosis ADD/ADHD Cancer Diabetes Epilepsy/Seizures Liver Disease High Blood Pressure Sleep Disorders (sleep apnea, insomnia) Intestinal Disorders (IBS, Ulcers) Psychiatric Disorders (depression, anxiety, etc.) Female Patients Only: Are you pregnant? Yes/No Are you currently breastfeeding? Yes/No Surgical History Please list the surgeries that you have had:
3 Drug and Alcohol History Do you currently use: Tobacco Yes/No number of cigarettes per day Alcohol Yes/No number of drinks per week Marijuana History Have you been evaluated by another physician for medical marijuana? Yes/No If yes, list the name of the practice, doctor, and date seen: Do you use marijuana 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 marijuana? ( )every day or almost every day ( )about 1-2 times per week ( )more than once a month What is your preferred method of using marijuana? ( ) smoke ( ) vaporizer ( ) ingested ( ) topical How effective is marijuana for your medical problem? ( ) very effective ( ) effective( ) only somewhat effective How does marijuana improve the quality of your life?
4 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 to the physician evaluation: 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 that 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. Patient s Signature Date Print Name
5 PATIENT ACKNOWLEDGEMENT I understand that: (Initial) The attending physician, staff and/or representatives are neither providing, dispensing nor encouraging me to obtain medical marijuana. The attending physician, staff and/or representatives 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 are addressing specific aspects of my medical card 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 physician. 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 California and have not misrepresented any information herein. I acknowledged 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, nor do I possess any recording equipment. I acknowledge that it is up to me to become a patient. If I decide not to be a patient after my evaluation, there will be no charge. In the event that I do pay and elect to be a patient, there will be no refunds. Patient Signature Date
6 INFORMED CONSENT I am being evaluated for a physician s recommendation for 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] 1. I must be a California resident to obtain an approval of recommendation for the use of cannabis (medical marijuana) under California Compassionate Use Act of 1996 (Health & Safety Code Section ). 2. The federal government has classified marijuana as a Schedule I controlled substance. Schedule 1 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 California, which have modified their state laws to treat marijuana as a medicine. 3. 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. 4. 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.
7 5. 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 cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. 6. 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. 7. I agree to contact you 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 you 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. 8. 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, 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. 9. 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). 10. 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 or if I think that I may be developing a dependency on marijuana, I should contact you.
8 11. Signs of withdrawal can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness. 12. 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 immediately go to the nearest emergency room. 13. If you subsequently learn 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 you and/or provide additional information in the event of any inaccuracies or misstatements in the information I have provided. 14. I have had, or will have, 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 that the physician has or will inform me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana. The 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 physician has, or will inform, me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits. Patient Signature: Date:
9 AUTHORIZATION FOR RELEASE OF INFORMATION Please initial next to each entry to which you agree: Initials: I hereby authorize you to disclose and verify my records as a patient to a marijuana dispensary or co-op for the purpose of obtaining marijuana. I understand that this authorization is valid for the period of time for which the recommendation for marijuana has been issued. I hereby authorize the use and disclosure of my patient records, except for personal identifying information, for use in data analysis of cannabis-treated patients I hereby authorize you to disclose and verify my medical records to law enforcement should I be arrested or detained related to my possession or use of marijuana. I understand that you will only provide verification of my patient status for the purpose of providing proof to justify my possession of marijuana. I understand that this authorization is valid for the period of time for which the recommendation for marijuana has been issued. Patient Name (Print): Patient Signature: Date:
10 VOLUNTARY STATE ID CARD PROGRAM RELEASE Information While you are extended all rights and privileges from Prop. 215 &S B 420 with a Physician s Recommendation Letter, you may apply for a Medical Marijuana Identification Card in the County in which you reside. This Identification card serves as evidence that you are authorized to possess and use Medical Marijuana as permitted under California law (Health & Safety Code Section et. seq.). State law does not require you to obtain an Identification Card. For more information on the Identification Card and registration program, you may go to the California Department of Public Health website at or call the Department at (916) If you are planning on obtaining a County ID card, please complete the following: Authorization for Release of In formation The undersigned hereby authorizes release of medical information to the California Department of Public Health and/or [insert the name of the County in which you reside] County Health Department as may be necessary for the issuance if a Medical Marijuana Identification Card and registration in the State database of authorized Identification Card holders. Except as permitted by State Law governing access to the Statewide Registry of Authorized Identification Card holders, information so disclosed may not be further disclosed or used by the recipient for any other purpose without my authorization. This authorization shall expire one (1) year from the date set forth below. Patient Name (Print): Patient Signature: Date: I acknowledge that I have been advised that I have a right to receive a copy of this authorization. (Initials)
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