PATIENT MEDICAL HISTORY INTAKE FORM

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Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information: Name: Date of Birth: Gender: Male Female Address: City: State: Zip: Phone: Email: Social Security Number (last 4) WHERE DID YOU HEAR ABOUT US? Have you brought medical records that document your medical condition? Yes For what condition do you seek medical marijuana?

Past Medical History: AIDS (Acquired Immune Deficiency Syndrome) ALS (Amyotrophic Lateral Sclerosis) Alzheimer s disease Arthritis: Autoimmune condition Back/neck injury/disease Blood disorders Brain disorders Breast lesions Cancer, Cachexia/Wasting Syndrome Chrohnʼs disease Chronic pain, Circulation (stroke, phlebitis, etc.) Diabetes Disc disease/injury: Dystonia (spasms, tremors) Ear problems tinnitus hearing loss) Eating disorder (anorexia, bulimia) Endocrine problems (thyroid, hormones) Fibromyalgia Eating disorder : anorexia : bulimia Epilepsy Glaucoma Hepatitis B Heart disease Hepatitis C High blood pressure HIV Intestinal disorders : ulcers : colitis : IBS Kidney disease : renal failure : cystitis Liver disease Lung disease (asthma, emphysema) Mental disorders (anxiety, bipolar, depression, PTSD, schizophrenia) Migraine headache Multiple sclerosis Persistent Muscle spasms Osteoporosis Parkinson s disease Prostate disease Rheumatic disease Sciatica Scoliosis Seizures Sleep disorders (insomnia, apnea) Weight loss/gain

Review of Symptoms: Check (x) symptoms that are current and you have been treated for in the past year: General: Gastrointestinal: Eye, Ear, Nose, Throat Chills Abdominal pain Bleeding gums Depression Appetite poor Blurred vision Dizziness Bloating Crossed Eyes Fainting Bowel changes Difficulty Swallowing Fever Constipation Double vision Forgetfulness Diarrhea Ear discharge Headache Excessive hunger Earache Loss of sleep Excessive thirst Hay fever Loss of weight Gas Hoarseness Nervousness Hemorrhoids Loss of hearing Numbness Indigestion Nosebleeds Poor energy Nausea Persistent cough Sweats Rectal bleeding Ringing in ears Stomach pain Sinus problems Vomiting Vision- flashes Vomiting blood Vision- Halos Muscle/Joint/Bone: Cardiovascular: Integumentary: (pain, weakness, numbness) Cardiac palpitations Bruise easily Arm Hip Chest pain or angina Change in moles Back Leg High blood pressure Hives Foot Neck Irregular heart beat Itching Hand Shoulder Low blood pressure Rash Arthritis Poor circulation Scars Muscle cramps Rapid heart rate Sore that wonʼt heal Swelling of ankles Varicose veins Psychiatric: Neurological: Respiratory: Anxiety Disturbance of speech Asthma Depression Dizziness, vertigo Bronchitis Disturbing feelings Fainting Cough

Panic attack Headache Cyanosis Restlessness Numbness Painful breathing Neurological: Respiratory: Seizures Pneumonia Tingling Shortness of breath Weakness Septum with blood Tuberculosis Endocrine: Genito-Urinary: Hematological/ Goiter Blood in urine Lymphatic Hot/Cold Intolerance Frequent urination Anemia Sexual dysfunction Lack of bladder control Bleeding tendency Menstrual Pain Blood disorder Pregnancy Surgical History: Please list any surgeries and date of such surgery: None: Surgery: Describe non-surgical treatments you have received/are receiving for your medical condition(s) for which you seek a recommendation of medical marijuana: physical therapy injections chiropractic acupuncture pain specialist talk therapist social worker psychiatrist orthopedist heart specialist nerve specialist oncologist endocrinologist other (specify): Medications: List all medications currently taking (include dosage, frequency of use: List any medications to which you are allergic: Are you currently receiving treatment/taking medication for the condition for which you are being evaluated for medical marijuana certification? Yes No What Treatment?

Activities of Daily Living Assessment: Please check if any of the following activities are substantially limited (i.e. pain/weakness/impaired strength or ability) by the medical condition for which you seek medical marijuana certification? caring for myself performing manual tasks seeing hearing eating sleeping walking standing lifting bending speaking breathing learning reading concentrating thinking communicating working social interaction operation of major bodily function other (please specify) Marijuana History: Do you presently use marijuana to treat your medical condition? : Yes : No Does marijuana provide relief for your symptoms (if yes, please describe, i.e. Lessens pain, improves sleep etc.): How effective is marijuana in treating the symptoms of your condition? Very effective Effective Somewhat effective How does marijuana compare with your usual prescribed medicines in relieving your symptoms? Prescribed medicines work much better Marijuana works a little better than prescribed medicines Prescribed medicines work a little better Marijuana works much better than prescribed medicines Prescribed medicines work no better Marijuana and prescribed medicines work best together

Does use of marijuana modify your use of other drugs?: Yes No Explain: Does use of marijuana modify your use of alcohol? Yes No Explain: Frequency of marijuana use as medicine (i.e. daily, weekly, monthly etc.): Method of marijuana use as a medicine: Vaporize Ingest Smoke Other You understand that smoking is harmful to your lungs and is not medically advised? Yes No Have you had any negative/adverse reaction from use of marijuana? No Yes (if yes, please describe) Additional Information that you consider relevant to physicians evaluation: My signature below attests to the fact that I have accurately and completely disclosed the requested information and indicates that I give permission to MariMed to verify my status as a patient in their office for the purpose of any certification that may be given with regard to the Humanitarian Medical Use of Marijuana. I do not waive any other patient and physician privacy rights under Federal HIPAA or Massachusetts State Laws. Patient Signature: Date:

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