Toggle navigation Exit and clear survey default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. MEDICAL CANNABIS PHYSICIANS OF FLORIDA NEW PATIENT INTAKE FORM(S) (This question is mandatory) Name: (This question is mandatory) Date of Birth: Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2037-12-31 MM-DD-YYYY Address: City: State: Zip Code: FL Driver's License #: Height: Feet: Inches: Weight: Lbs. Social Security Number: (This question is mandatory) Phone No.: (This question is mandatory) E-Mail: (This question is mandatory) PERSONAL MEDICAL HISTORY: Check all that apply Chronic Pain COPD/ Emphysema Crohn’s Disease Dementia Depression Diabetes: 1 or 2 Diverticulitis DVT (Blood Clot) Endometriosis Fibromyalgia GERD (Acid Reflux) Glaucoma Heart Disease Heart Attack (MI) Hiatal Hernia High Blood Pressure Kidney Stones Kidney Disease High Cholesterol HIV/AIDS Hepatitis Irritable Bowel Syndrome Lupus Liver Disease Macular Degeneration Migranes Multiple Sclerosis Neuropathy Osteopenia/Osteoporosis Parkinson’s Disease Peripheral Vascular Disease Peptic Ulcer Post Traumatic Stress Disorder (PTSD) Psoriasis Pulmonary Embolism (PE) Rheumatoid Arthritis Seizure Disorder Sleep Apnea Stroke Thyroid Disorder Ulcerative Colitis Please list symptom(s) you experience: Symptom #1 Symptom #2 Please describe previously listed symptom(s) frequency, severity and duration: Symptom #1 Symptom #2 None Slightly Some What Very Extreme No answer None Slightly Some What Very Extreme No answer Severity Symptom #1 None Slightly Some What Very Extreme No answer Symptom #2 None Slightly Some What Very Extreme No answer Frequency Symptom #1 None Slightly Some What Very Extreme No answer Symptom #2 None Slightly Some What Very Extreme No answer Duration Symptom #1 None Slightly Some What Very Extreme No answer Symptom #2 None Slightly Some What Very Extreme No answer Please list all treatments you’ve tried, length of each treatment attempted, and their outcomes: Comment only when you choose an answer. Treatment: Duration: Outcome: Please list all current medications, the dosage, and how many times a day you take them: Comment only when you choose an answer. Name of Medication Dosage Frequency Please list any allergies: (This question is mandatory) Do you smoke cigarettes? Yes No Please enter your comment here: If yes, please type how many per day and for how many years in the comments (This question is mandatory) Do you drink alcohol? Yes No Please enter your comment here: If yes, please type how much and how often in the comments (This question is mandatory) Do you use recreational drugs? Yes No Please enter your comment here: If yes, please type the specific drug and how often in the comments Are you currently, or have you ever used Marijuana before in the past? Please select at most one answer I am currently using Marijuana I have previously used Marijuana (but am not currently) I have never used Marijuana before Other medical problems not listed above: List all prior surgeries and approximate dates performed: List any other medical providers you see on a regular basis: i.e. Cardiologist, Mental Health Provider, Kidney Doctor, Dentist, etc. Submit Please confirm you want to clear your response? Exit and clear survey ×
