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 FL NEW PATIENT INTAKE FORM(S) (This question is mandatory) Name: 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: Phone No.: E-Mail: Primary Care Physician: Phone No.: Reason for Cannabis Treatment: Muscle Spasms Seizures Cancer Glaucoma Crohn's Disease HIV/AIDS PTSD ALS Parkinson’s Disease Multiple Sclerosis Terminal Illness Severe Nausea Paraplegia Quadriplegia Chronic Pain Other: No answer Please list symptom(s) you experience: Symptom #1 Symptom #2 Please describe previously listed symptom(s) frequency, severity and duration: Symptom #1 Symptom #2 Not At All Slightly Moderately Very Extremely No answer Not At All Slightly Moderately Very Extremely No answer Severity Symptom #1 Not At All Slightly Moderately Very Extremely No answer Symptom #2 Not At All Slightly Moderately Very Extremely No answer Frequency Symptom #1 Not At All Slightly Moderately Very Extremely No answer Symptom #2 Not At All Slightly Moderately Very Extremely No answer Duration Symptom #1 Not At All Slightly Moderately Very Extremely No answer Symptom #2 Not At All Slightly Moderately Very Extremely 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: Do you smoke cigarettes? Yes No No answer Please enter your comment here: If yes, please type how many per day and for how many years in the comments Do you drink alcohol? Yes No No answer Please enter your comment here: If yes, please type how much and how often in the comments Do you use illegal drugs? Yes No No answer Please enter your comment here: If yes, please type the specific drug and how often in the comments Please list all your medical illnesses: 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: PERSONAL MEDICAL HISTORY: Check all that apply Headaches Crohn’s Disease COPD/ Emphysema Dementia Depression Diabetes: 1 or 2 Diverticulitis DVT (Blood Clot) GERD (Acid Reflux) Glaucoma Heart Disease Heart Attack (MI) Hiatal Hernia High Blood Pressure Kidney Stones Kidney Disease High Cholesterol HIV Hepatitis Irritable Bowel Syndrome Lupus Liver Disease Macular Degeneration Neuropathy Osteopenia/Osteoporosis Parkinson’s Disease Peripheral Vascular Disease Peptic Ulcer Psoriasis Pulmonary Embolism (PE) Rheumatoid Arthritis Seizure Disorder Sleep Apnea Stroke Thyroid Disorder Ulcerative Colitis Cancer: (please specify type) Date of last menstrual period: Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2037-12-31 MM-DD-YYYY Yes No No answer Was your period abnormal? Date of last colonoscopy: Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2037-12-31 MM-DD-YYYY Yes No No answer Were there any abnormal findings during your colonoscopy? Date of last mammogram Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2037-12-31 MM-DD-YYYY Yes No No answer Were there any abnormal findings during your mammogram? Date of last Dexa (Bone Density) Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2037-12-31 MM-DD-YYYY Yes No No answer Were there any abnormal findings during your Dexa? Date of last Pap Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2037-12-31 MM-DD-YYYY Yes No No answer Were there any abnormal findings during your Pap? Other medical problems not listed above: Education Level: Elementary High School Vocational College Graduate / Professional Are there any vision problems that affect your communication? Yes No No answer Are there any hearing problems that affect your communication? Yes No No answer Are there any limitations to understanding or following instructions? Yes No No answer Current Living Situation: Check all that apply Single Family Household Multi-generational Household Homeless Shelter Skilled Nursing Facility Other: Are you sexually active? Yes No No answer Are there any personal problems or concerns at home, work, or school you would like to discuss? Yes No No answer Are there any cultural or religious concerns you have related to our delivery of care? Yes No No answer Are there any financial issues that directly impact your ability to manage your health? Yes No No answer How often do you get the social and emotional support you need? Always Usually Sometimes Rarely Never No answer Comments: Please feel free to comment on any answers marked “yes” above Is your father still alive? Yes No If yes, current age? Did your father have any of the following conditions? Check all that apply Alcoholism Anemia Asthma Arthritis Bipolar Disorder Cancer COPD/Emphysema Dementia Depression Diabetes 1 or 2 DVT (Blood Clot) Heart Disease High Cholesterol High Blood Pressure Kidney Disease Migraines Osteoporosis Stroke Thyroid Disorder Other: Is your mother still alive? Yes No If yes, current age? Did your mother have any of the following conditions? Check all that apply Alcoholism Anemia Asthma Arthritis Bipolar Disorder Cancer COPD/Emphysema Dementia Depression Diabetes 1 or 2 DVT (Blood Clot) Heart Disease High Cholesterol High Blood Pressure Kidney Disease Migraines Osteoporosis Stroke Thyroid Disorder Other: Number of Siblings: List 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 ×
