New Patient Medical History and Intake Form

Medical Marijuana (“MMJ”) Certification

Please correct the errors described below.

Other Medical Problems and/or Symptoms

Add Other Medical Problems and/or Symptoms

Past Medical History: Please note if you have had any of the following Medical Illnesses / Problems

Surgical History: Please note if you have had any surgeries and write date of such surgery


Medications: Please list ALL medications/herbs you are taking.

Add new row

Review of Systems Checklist: (Please check all that apply to your current condition)

(Start Date)

Psychiatric History

Pain Questionnaire

My signature below attests to the fact that I have read and accurately completed this form to the best of my knowledge. All information regarding my medical condition and the records I am submitting is completely truthful and represents the medical condition for which I am seeking treatment. I voluntarily consent to this evaluation and understand that I am solely responsible for payment for services.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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