Pre-Visit Questionnaire

Date

Name*

First NameLast Name

Date of Birth*

Height

In feet and inches

Weight

In pounds

Gender/Preferred Pronoun:

Address

Street Address Line 2

CityState/Zip

Last four of SSN:*

Email*

example@example.com

Please upload a copy of your Massachusetts driver’s license or state ID card when returning this form for proof of residence.

If applicable, please upload proof of Medicaid, SNAP, WIC, FPHA, SSDI or veteran status.

File Upload*

Browse Files

Current medical complaint: (List the medical problems for which you use or would like to use medical marijuana)

Primary care provider:

Date of last visit:

Month and Year

Medications: List all of your medications include prescription, herb, and over-the-counter.*

Allergies: List all allergies and allergic reaction. If none, please state “none".*

Do you have or have you ever had any of the following medical problems?

Are you pregnant or plan to become pregnant:

Please list the surgeries that you have had, please include date of surgery and location:

Tobacco Yes/No *

Number of packs per day

Alcohol Yes/No*

Number of drinks per week

Other substance use history:

Cocaine/MethOpiates/Prescription opiates/heroin/methadoneHallucinogens/ecstasy/LSD/mushrooms

Please list any family members (Mother, Father, Brother, Sister, Child, Grandparent) with a history of Alcoholism or Drug Abuse:

Have you been evaluated by another physician for medical marijuana?*

If yes, where and when:

Do you use marijuana to reduce or eliminate the use of any medications that have been prescribed for your medical condition?*

If yes, which medication have you reduced or eliminated and why?

How often do you use marijuana?

every day or almost every dayabout 1-2 times per weekmore than once a monthnever

Occupation:

Employer:

Other than your primary care provider listed above, are you seeing any other provider/specialist on a regular basis?

I understand that the information I have been asked to provide is for the diagnosis and treatment of the medical condition for which I am seeing the physician today, and that if I have not accurately and completely disclosed the requested information, it may adversely impact the physician’s ability to diagnose my condition and recommend appropriate treatment. I certify that the information in this questionnaire is accurate and complete.

Name*

First NameLast Name

Date*

Date

By signing this page, you are acknowledging that:

This telehealth visit is limited to the evaluation for use of medical marijuana. Upon completion of this form and video telehealth visit, Dr. Neil Kudler will provide the appropriate paperwork that is required for submission to the Commonwealth of Massachusetts if Dr. Neil Kudler determines that the use of medical marijuana is appropriate.

Dr. Kudler is neither providing nor dispensing medical marijuana. He will not provide information about purchasing, selecting, or use of medical marijuana.

Dr. Kudler is not available for continuity or primary care. Should there be medical concerns that do not pertain to this evaluation, you are advised to seek the advice of your primary care provider.

Please review and acknowledge:*

I acknowledge that I am a resident of The Commonwealth of Massachusetts and have not misrepresented any information herein.I acknowledged that I am not an agent of law enforcement, either State or Federal or local government, here for the purpose of investigation or entrapment.I acknowledge that I am not recording any portion of my visit, nor do/will I have any recording equipment in my possession.

Patient Signature:

Name

First NameLast Name

Date:

Date

I am being evaluated for a physician’s certification that I meet the criteria set forth in Massachusetts State law for medical marijuana. Dr. Neil Kudler will make this certification based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non-medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, growing of, sale/purchase and/or distribution of marijuana. I have been informed of and understand the following: [please initial each item]

1. I must be a Massachusetts resident to obtain an approval of recommendation for the use of cannabis.*

Initial Here

2. The federal government has classified marijuana as a Schedule I controlled substance. Schedule 1 substances are defined, in part, as having (1) a high potential for abuse; (2) not currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution, and possession of marijuana even in medically legal states which have modified their state laws to treat marijuana as a medicine.*

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3. Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore the “manufacture” of marijuana for medical use is not subject to any standards, quality control, or other oversight.*

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4. The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana, I should not drive, operate heavy machinery, or engage in any activities that require me to be alert and/or respond quickly. I understand that if I drive while under the influence of marijuana, I can be arrested for “driving under the influence”.*

Initial Here

5. Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short-term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of marijuana may cause me to talk or eat in excess, alter my perception of time and space, and impair my judgment*

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6. I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.*

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7. Women should not consume cannabis products while planning to become pregnant, during pregnancy, or while breast feeding, except on the advice of the certifying health practitioner, and in the case of breast feeding mothers, on the advice or the infant’s pediatrician. Using cannabis while under the influence of alcohol is not recommended.*

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8. I agree to contact my primary care provider or the nearest emergency department if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact my primary care provider or nearest emergency department if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.*

Initial Here

9. Smoking marijuana may cause respiratory problems and harm, including bronchitis, emphysema, and laryngitis. In the opinion of many researchers, marijuana smoke contains known carcinogens (chemicals that can cause cancer) and smoking marijuana may increase the risk of respiratory diseases and cancers in the lung, mouth and tongue. In addition, marijuana smoke contains harmful chemicals known as tars. If I begin to experience respiratory problems when using marijuana, I will stop using it and report my symptoms to a physician.*

Initial Here

10. The risks, benefits and drug interactions of marijuana are not fully understood. If I am taking medication or undergoing treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s).*

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11. Individuals may develop a tolerance to, and/or dependence on, marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should seek treatment with my primary care doctor or addiction medicine specialist.*

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12. Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to immediately go to the nearest emergency room.*

Initial Here

13. If Dr. Kudler subsequently learns that the information I have furnished is false or misleading, the recommendation for marijuana may no longer be valid and that the Department of Public Health will receive notice of this fraudulent behavior. I agree to promptly contact him and/or provide additional information in the event of any inaccuracies or misstatements in the information I have provided.*

Initial Here

14. I have had, or will have, the opportunity to discuss these matters with Dr. Kudler and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that Dr. Kudler has not provided a recommended treatment of my condition with medical marijuana. This document outlines and informs me of the risks, complications of any recommended treatment I choose to undertake under my own judgement (under the laws of the State of MA) after obtaining the certificate.*

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15. I, for myself, my heirs, assigns, or anyone acting on my behalf, hold Dr. Neil Kudler and his agents, and employees free of and harmless from any responsibility for any harm resulting to me and/or other individuals because of my Medical Marijuana use. I certify that I fully understand the potential risks and side effects related to the use of Medical Marijuana as described above. In using Medical Marijuana, I fully accept responsibility and assume the risks and side effects associated with its use.*

Initial Here

Patient signature:

Name*

First NameLast Name

Date:*

“Mass Legal requirement per105 CMR 725.000: IMPLEMENTATION OF AN ACT FOR

THE HUMANITARIAN MEDICAL USE OF MARIJUANA

725.010: Certifying Physician’s Written Certification of a Debilitating Medical Condition for a Qualifying Patient 1. Such program must explain the proper use of marijuana, including side effects, dosage, and contraindications, including with psychotropic drugs, as well as on substance abuse recognition, diagnosis, and treatment related to marijuana.”

Dr. Kudler is providing you with this listing of the common concerns from the medical community regarding cannabis: General Remarks: Deaths due to cannabis use are not known. The median lethal dose in rats was 800 to 1,900 mg (depending on strain) oral THC per kilogram body weight. In studies with monkeys no deaths were recorded following the highest applied doses of 9,000 mg/kg oral THC. All possible side effects are dose dependent. Therapy should always start with low doses, slowly increasing, so that the individual dose can be determined and unwanted effects can be avoided. Acute side effects: Known psychic side effects are sedation, euphoria high, dysphoria, fear to die, feeling to lose control, impairment of memory, altered time perception, depression, hallucinations. In case of strong psychic side effects, the affected should be brought to a calm place and “talked down”. Cognition and psychomotor performance are attenuated. A discrete reduction of psychomotor performance may be observed up to 24 hours after the administration of THC. Frequent acute physical side effects are dry mouth, movement disorder, muscle weakness, slurred speech, increase of heart rate, decrease of blood pressure in vertical position, eventually with dizziness. In case of dizziness the affected should lay down. In horizontal position a slightly higher blood pressure may be measured. Rare side effects are nausea and headaches. All acute side effects are dose dependent and generally disappear within hours or 1- 3 days without specific treatment. Side effects of long-term therapy: Development of tolerance is described for a multitude of effects, among them psychic actions, psychomotor impairment, effects on heart and circulation, effects on the hormonal system, intraocular pressure, and anti-emetic effects. Tolerance means that the effect decreases with time during use of cannabis. Tolerance may appear with repeated doses within weeks with different extent for different effects. Cannabis possesses a potential for addiction. Dependency may not be a relevant problem within the bounds of therapy of diseases, but withdrawal may be unwanted. Withdrawal have not been described in patients that were long-term treated with THC. But withdrawal has been observed in recreational users. Thereby psychic symptoms (anxiety, restlessness, insomnia) and physical symptoms (salivation, diarrhea) may occur. The course of a psychosis may be influenced unfavorably. In vulnerable persons the onset of a psychosis may be accelerated or triggered. Cannabinoids may exert complex effects on male and female sex hormones, their clinical relevance in therapeutic doses being low. Occasionally menstrual cycles without ovulation and impairment of sperm production have been described. I have read this entire document and my questions have been answered by Dr.Kudler regarding the safety and risk associated with cannabis usage.

Patient Signature:

Date:*

Medical History:

Surgical History:

Drug and Alcohol History:

Family History of Alcohol and Drug Use:

Marijuana History:

Social History:

Other Providers/Specialists:

Consent:

Important Patient Acknowledgements

Informed Consent