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

Allergies

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.

Your information will be encrypted.

Loading...