PATIENT INFORMATION

PATIENT INFORMATION

*Date ______________________

__________________________________

*Last Name

_______________________________________

*First Name

________

M.I.

___________________________________________________Apt # ____________________________________________________

*Residential Address

City*

State*

Zip*

___________________________________________________Apt #_____________________________________________________

*Mailing Address (If different from above)

City*

State*

Zip*

*Are you requesting to Cultivate? ______ Yes ______ No (YOU MUST LIVE 25 MILES AWAY FROM AN OPERATING DISPENSARY)

* Is a Caregiver being designated? _______ Yes _______ No

__________________________________________ *Patient Cell Number

___________________________________________ *Patient Home Number

*Patient Birth Date

___________________________

*Current Age: _____

Sex: M / F

_________________________________________________ *How did you hear about us? (Name and/or Phone# if applicable)

__________________________________________________ *What is Your Email Address

Emergency Contact: ___________________________________________________________________________

Name

Relationship

Phone#

What qualifying condition are we seeing you for? (MUST BE FILLED OUT) Please circle any that apply:

1. Cancer 2. Glaucoma 3. HIV 4. AIDS 5. Hepatitis C 6. ALS 7. Crohn's Disease 8. Agitation of Alzheimer 's disease

9. PTSD 10. Cachexia or wasting syndrome 11. Severe and chronic pain 12. Severe Nausea

13. Seizures/Epilepsy

14. Multiple Sclerosis Other:___________________________________________________________________________

* = MUST BE FILLED OUT COMPLETELY

State Fee (VISA or MasterCard): Office Fee (Cash): Exam / Medical Records: Referral: Other: New Card / Renewal Food Stamps Y / N Needs Exam Y / N

FOR OFFICE USE ONLY

PQ_________________________________ Copy of ID___________________________ Scanned ID__________________________ Scanned Attest_______________________ Copy of SNAP________________________ Scanned SNAP________________________ Scan/Copy Cert_______________________ Photo_______________________________

MARIJUANA PROGRAM PATIENT ATTESTATION

I, __________________________________ , attest that:

I will not divert marijuana to any individual who or entity that is not allowed to possess marijuana pursuant A.R.S. Title 36, Chapter 28.1 and that the information provided in the application is true and correct.

______________________________________ Signature

___________________________________ Date Signed

PATIENT INTAKE FORM

Patient Name: __________________________________________________ 1. Indicate on the drawings below where you may have pain/symptoms:

Date: _________________________

2. How often do you experience symptoms?

____ Constantly (76-100% of the time)

____ Occasionally (26-50% of the time)

____ Frequently (51-75% of the time)

____ Intermittently (1-25% of the time)

3. How would you describe the type of pain?

___ Sharp

___ Burning

___ Tingly

___ Electric w/ motion

___ Dull

___ Shooting

___ Sharp w/ motion ___ Other

___ Diffuse

___ Stiff

___ Shooting w/ motion

_________________________

___ Achy

___ Numb

___ Stabbing w/ motion

4. How are your symptoms changing w/ time?

____ Getting Worse

____ Staying the Same

____ Getting Better

5. Using a scale from 1 ? 10 (10 being the worst), how would you rate your problem at its worst? Please Circle

0

1

2

3

4

5

6

7

8

9

10

6. How much has the problem interfered with your work?

___ Not at all

___ A little bit

___ Moderately

___ Quite a bit

___ Extremely

7. How much has the problem interfered with your social activities?

___ Not at all

___ A little bit

___ Moderately

___ Quite a bit

___ Extremely

8. Who else have you seen for this problem in the past 12 months?

___ Chiropractor

___ Neurologist

___ Primary Care Physician

___ ER Physician

___ Orthopedist

___ Other:____________________

___ Massage Therapist

___ Physical Therapist ___ No one

9. How long have you had this problem? _______________________________________________________________

10. How do you think your problem began? ______________________________________________________________

11. Do you consider this problem to be severe or chronic? ____ Yes

____ At times

____ No

12. What aggravates your problem? ____________________________________________________________________

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13. What is your: Height ___________ Weight ___________ Date of Birth ______________________

14. How would you rate your overall health? ____ Excellent ____ Very Good ____ Good _____ Fair ____ Poor

15. Indicate if you have any immediate family members with any of the following:

____ Rheumatoid Arthritis ____ Diabetes

____ Lupus ____ Heart Problems

____ Cancer

____ ALS

16. For each of the conditions listed below, place a check in the `past' column if you have had the condition in the past. If you presently have a condition listed below, place a check in the `present' column...

Past

Present

___

___ Headaches

___

___ Neck Pain

___

___ Upper Back Pain

___

___ Mid Back Pain

___

___ Lower Back Pain

___

___ Shoulder Pain

___

___ Elbow/Upper Arm Pain

___

___ Wrist Pain

___

___ Hand Pain

___

___ Hip Pain

___

___ Upper Leg Pain

___

___ Knee Pain

___

___ Ankle/Foot Pain

___

___ Jaw Pain

___

___ Abdominal Pain

___

___ Joint Pain/ Stiffness

___

___ Arthritis

___

___ Rheumatoid Arthritis

___

___ Cancer

___

___ Tumor

Past

Present

___

___ Asthma

___

___ Fibromyalgia

___

___ Kidney Disorders

___

___ Hepatitis C

___

___ HIV / AIDS

___

___ Glaucoma

___

___ ALS

___

___ Crohn's Disease

___

___ Alzheimer's

___

___ PTSD

___

___ Cachexia / Wasting Syndrome

___

___ Severe Nausea

___

___ Loss of Appetite

___

___ Abnormal Weight Gain/Loss

___

___ Seizures

___

___ Epilepsy

___

___ Pregnancy

___

___ Diabetes

___

___ Prostate Problems

___

___ Muscular Incoordination

17. List All OTC (over the counter) medications you are currently taking: _______________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

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18. List all or any surgical procedures you have had that pertain to the condition we are seeing you for: __________________________________________________________________________________________________ __________________________________________________________________________________________________ 19. Have you been hospitalized in the past 12 months? ____ Yes ____ No If Yes, why _________________________ __________________________________________________________________________________________________ 20. Have you had significant past trauma pertaining to your qualifying condition? __________________________________________________________________________________________________ __________________________________________________________________________________________________ 21. Allergy Information: Are you allergic to any type of medication? Yes / No

If yes please list: _____________________________________________________________________________________

22. Are you or is there a possibility that you may be pregnant? ____ Yes ____ No

Patient Signature: ___________________________________

Date: _____________________

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