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? ____________________________________________________________________
Page 1 of 3
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: _______________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
Page 2 of 3
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: _____________________
Page 3 of 3
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