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5332307000296693200036385526860500533400000First Name: Middle Name: Last Name: 54800502857500028363332715680036385527051000Address: City: State: Zip Code: 5757341143000Date of Birth:General overall assessment of symptoms (0-10): _________Symptom Scale:0Symptom Free1Very minor symptoms/annoyance; no medication needed2Minor symptoms/annoyance; no medication needed3Symptoms annoying enough to be distracting; mild medications relieve symptoms4Symptoms can be ignored if you are really involved in your work, but still distracting; mild painkillers, muscle relaxants, etc. alleviate pain for 3-4 hours5Symptoms cannot be ignored for more than 30 minutes; mild painkillers, muscle relaxants, etc. reduce pain for 3-4 hours6Symptoms cannot be ignored for any length of time; can still go to work and participate in social events; stronger painkillers, muscle relaxants, etc. reduce pain for 3-4 hours7Symptoms make it difficult to concentrate, interferes with sleep; can still function with effort; stronger painkillers, muscle relaxants, etc. are only partially effective8Physical activity severely limited due to symptoms; you can read and converse with effort; nausea and dizziness set in as factors of your symptoms9Unable to speak; crying out or moaning uncontrollably; near delirium due to symptoms10Unconscious; symptoms make you pass outApproximate date (month/year) of onset of the debilitating condition that has led to this evaluation for the possible use of medical marijuana: _________________________Medications:Allergies: Social History:Past Medical History:4359910372110OsteoarthritisRheumatoid ArthritisAllergic RhinitisDepressionAnxiety DisorderPanic AttacksBipolar DisorderSchizophreniaPost-Traumatic Stress DisorderPsychotic Disorder: _____________AutismDementia/Alzheimer’s DiseaseADD/ADHDGlaucomaTerminal Illness:Cachexia and Wasting SyndromeCancerSurgeryChemoRadiationBrainY / NY / NY / NBreastY / NY / NY / NCervicalY / NY / NY / NColonY / NY / NY / NLeukemiaY / NY / NY / NOvarianY / NY / NY / NOsteosarcomaY / NY / NY / NProstateY / NY / NY / NTesticularY / NY / NY / NUterineY / NY / NY / NLungY / NY / NY / NSkinY / NY / NY / NStomachY / NY / NY / NThyroidY / NY / NY / NOther:Y / NY / NY / N020000OsteoarthritisRheumatoid ArthritisAllergic RhinitisDepressionAnxiety DisorderPanic AttacksBipolar DisorderSchizophreniaPost-Traumatic Stress DisorderPsychotic Disorder: _____________AutismDementia/Alzheimer’s DiseaseADD/ADHDGlaucomaTerminal Illness:Cachexia and Wasting SyndromeCancerSurgeryChemoRadiationBrainY / NY / NY / NBreastY / NY / NY / NCervicalY / NY / NY / NColonY / NY / NY / NLeukemiaY / NY / NY / NOvarianY / NY / NY / NOsteosarcomaY / NY / NY / NProstateY / NY / NY / NTesticularY / NY / NY / NUterineY / NY / NY / NLungY / NY / NY / NSkinY / NY / NY / NStomachY / NY / NY / NThyroidY / NY / NY / NOther:Y / NY / NY / N1608455313055Inflammatory Bowel Disease Crohn’s DiseaseUlcerative Colitis CVA (Stroke)TIA (Mini-Stroke)Seizure disorder (epilepsy)MigrainesAmyotrophic Lateral SclerosisHuntington’s DiseaseNeuropathiesFibromyalgiaDeep Vein Thrombosis (DVT)ObesityObstructive Sleep ApneaNephrolithiasis (Kidney Stone)Chronic Renal FailureChronic Renal Insufficiency DiabetesType IType IILiver DysfunctionEnd Stage Liver DiseaseCirrhosisFatty Liver DiseaseHepatitis AHepatitis BHepatitis CHepatitis DHepatitis E HIV/AIDSBenign Prostatic Hypertrophy (BPH)Erectile Dysfunction (ED)Urinary Incontinence 020000Inflammatory Bowel Disease Crohn’s DiseaseUlcerative Colitis CVA (Stroke)TIA (Mini-Stroke)Seizure disorder (epilepsy)MigrainesAmyotrophic Lateral SclerosisHuntington’s DiseaseNeuropathiesFibromyalgiaDeep Vein Thrombosis (DVT)ObesityObstructive Sleep ApneaNephrolithiasis (Kidney Stone)Chronic Renal FailureChronic Renal Insufficiency DiabetesType IType IILiver DysfunctionEnd Stage Liver DiseaseCirrhosisFatty Liver DiseaseHepatitis AHepatitis BHepatitis CHepatitis DHepatitis E HIV/AIDSBenign Prostatic Hypertrophy (BPH)Erectile Dysfunction (ED)Urinary Incontinence -6858004406900AsthmaPulmonary EmbolismChronic Obstructive Pulmonary Disease (COPD)AnemiaSickle Cell AnemiaBleeding Disorder: __________Thyroid DisorderHypothyroidismHyperthyroidismGERD (Gastroesophageal Reflux Disease)Peptic Ulcer Disease (PUD)00AsthmaPulmonary EmbolismChronic Obstructive Pulmonary Disease (COPD)AnemiaSickle Cell AnemiaBleeding Disorder: __________Thyroid DisorderHypothyroidismHyperthyroidismGERD (Gastroesophageal Reflux Disease)Peptic Ulcer Disease (PUD)-453390291140Chronic Pain Syndrome (chronic, persistent)HypertensionCoronary Artery DiseaseMyocardial Infarction (Heart Attack)Congestive Heart Failure (CHF)Cardiac ArrhythmiaAtrial FibrillationSVTHeart BlockPAC/PVCDefibrillator PlacementPacemaker PlacementElevated Cholesterol/DyslipidemiaChronic Persistent Muscle Spasms Associated with:Multiple SclerosisSeizure DisorderParkinson’s DiseaseTourette’s SyndromeOther:020000Chronic Pain Syndrome (chronic, persistent)HypertensionCoronary Artery DiseaseMyocardial Infarction (Heart Attack)Congestive Heart Failure (CHF)Cardiac ArrhythmiaAtrial FibrillationSVTHeart BlockPAC/PVCDefibrillator PlacementPacemaker PlacementElevated Cholesterol/DyslipidemiaChronic Persistent Muscle Spasms Associated with:Multiple SclerosisSeizure DisorderParkinson’s DiseaseTourette’s SyndromeOther:Family History of Schizophrenia or Psychosis: Yes/No Details: _____________________________________________Family History of Substance Abuse: Yes/No Details: ____________________________________________________-154172280360TonsillectomyAppendectomyCholecystectomy (Gallbladder Removal)Cardiac Valve Replacement/RepairCoronary Artery Bypass Grafting (CABG)Cardiac CatheterizationWith StentWithout StentHernia RepairCesarean Section x _______Eye SurgeryOpen Reduction Internal Fixation (ORIF)Left Upper ExtremityRight Upper ExtremityLeft Lower ExtremityRight Lower Extremity00TonsillectomyAppendectomyCholecystectomy (Gallbladder Removal)Cardiac Valve Replacement/RepairCoronary Artery Bypass Grafting (CABG)Cardiac CatheterizationWith StentWithout StentHernia RepairCesarean Section x _______Eye SurgeryOpen Reduction Internal Fixation (ORIF)Left Upper ExtremityRight Upper ExtremityLeft Lower ExtremityRight Lower Extremity2449520283062Lithotripsy AmputationUpper Extremity (L/R/B)Lower Extremity (L/R/B)Sterilization (Tubal Ligation or Vasectomy)Excision of Skin CancerBreast BiopsyMastectomyLumbar SurgeryWith Fusion x ____Without Fusion x ____Cervical Neck SurgeryWith Fusion x ____Without Fusion x ____020000Lithotripsy AmputationUpper Extremity (L/R/B)Lower Extremity (L/R/B)Sterilization (Tubal Ligation or Vasectomy)Excision of Skin CancerBreast BiopsyMastectomyLumbar SurgeryWith Fusion x ____Without Fusion x ____Cervical Neck SurgeryWith Fusion x ____Without Fusion x ____4374663260350Port PlacementThyroidectomyD&CBariatric Surgery (weight loss)Pacemaker PlacementDefibrillator PlacementEGDColonoscopyHysterectomyHip replacement (L/R/B)Knee Replacement (L/R/B)Knee Arthroscopy (L/R/B)Shoulder arthroscopy (L/R/B)Dental SurgeryDiagnostic LaparoscopyOther: ____________________020000Port PlacementThyroidectomyD&CBariatric Surgery (weight loss)Pacemaker PlacementDefibrillator PlacementEGDColonoscopyHysterectomyHip replacement (L/R/B)Knee Replacement (L/R/B)Knee Arthroscopy (L/R/B)Shoulder arthroscopy (L/R/B)Dental SurgeryDiagnostic LaparoscopyOther: ____________________Past Surgical History:Employment: employed/unemployed/retired/disabledCriminal History relating to possession/intoxication/distribution of drugs: yes/noPast History/Experience with marijuana: yes/noBeneficial at reducing symptoms related to your debilitating condition: yes/no Past History of Substance Misuse or Abuse (including treatment for chemical dependence):Substance Yes NoLast UseTreatment:Yes NoAlcoholCocaineInhalantsMethamphetaminesOpioids LSD or hallucinogensMarijuanaEcstasyPCPBenzodiazepinesStimulantsOtherPrevious TreatmentsImprovementsMedicationsOpioidsNSAIDSMuscle RelaxantsAnticonvulsantsBenzodiazepinesMigraine MedicationsAnti-anxiety MedicationsY / NY / NY / NY / NY / NY / NY / NChemotherapyY / NRadiationY / NInfusion TherapyY / NPhysical TherapyY / NHome Exercise ProgramY / NChiropractic TreatmentY / NInterventional ProceduresTrigger Point InjectionLocation:Y / NEpidural Steroid Injection:Cervical Y / NThoracic Y / NLumbar Y / NInterventional Procedures Cont.ImprovementsFacet or Medial Branch Blocks:Cervical Y / NThoracic Y / NLumbar Y / NRadiofrequency Thermocoagulation (RFTC):Cervical Y / NThoracic Y / NLumbar Y / NSacroiliac Joint Injection/RFTCY / NSpinal Cord StimulationY / NIntrathecal Pain PumpY / NJoint InjectionLocation:Y / NBotox InjectionY / NSuperior Hypogastric Plexus Block/RFTCY / NSplanchnic Nerve Block/RFTCY / NCeliac Plexus Block/RFTCY / NLumbar Sympathetic Block/RFTCY / NSuprascapular Nerve Block/RFTCY / NTrigeminal Nerve Block/RFTCY / NOccipital Nerve Block/RFTCY / N 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