CANNABIS CARE INTAKE FORM

PATIENT INTAKE AND MEDICAL HISTORY FORM

DR SAM 420
FOR INDIVIDUALS WHO ARE PENNSYLVANIA RESIDENTS AGE 18 AND OLDER

IF YOU ARE UNDER 18, PLEASE STOP HERE.

• Payment for the consultation with Dr. Sam is due at the time of the scheduled consultation.

• Some employers may ask for proof that you can work safely when using medical marijuana. We can acknowledge that you are certified but cannot give a time frame for them on how long the THC will remain in your system or what effect it will have on impairement (just as we cannot commment on how long a medication like ativan or xanax (benzodiazepines) can impair you).

• WHEN COMPLETING THE FORM, YOU WILL NEED TO FILL IN EACH FIELD MARKED BY AN ASTERISK *. Your submission is completed if a screen pops up after submission stating "THANK YOU FOR YOUR SUBMISSION" with a GREEN CHECK MARK.
Patient Name*

First NameMiddle NameLast Name
Guardian Name (If patient is unable to sign)

First NameLast Name
Todays Date

MonthDayYear
Patient Information
Date of Birth*

MonthDayYear
ADDRESS MUST Match PA Driver License/Photo ID card - WHATEVER PENNDOT has on file for your address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*
Cell Phone
Patient E-Mail*
Current Occupation
retired/unemployed may be listed
Emergency Contact
IF WE ARE UNABLE TO CONTACT YOU, THIS NAMED PERSON HAS PERMISSION FOR US TO DISCUSS YOUR CERTIFICATION, MEDICAL CONDITIONS OR APPOINTMENT SCHEDULING. IF YOU DO NOT WISH TO LIST ANYONE PLEASE TYPE "NONE" IN THE FIELD ABOVE UNDER "EMERGENCY CONTACT"
Relationship to Patient
Emergency Contact Phone Number

Area CodePhone Number
Race
Did someone refer you/how did you hear about us? ((example: google, dispensary,
Is this INITIAL or RECERTIFICATION ?*
Is there a particular time of day Monday-Friday that we can contact you to schedule your certification call or when you are free to speak for the consultation?*
Reason for Medical Marijuana Evaluation
Please check the box next to the qualifying medical condition(s) for which you believe you are a candidate for medical marijuana.*

AnxietyAmyotrophic Lateral Sclerosis (Lou Gherig's disease)AutismCancer (or in remission)Ulcerative ColitisCrohn's DiseaseDamage to the Nervous tissue of the Spinal Cord (with spasticity)Epilepsy or Intractable SeizuresGlaucomaHIV/AIDSSevere Chronic/Intractable Pain of Neuropathic OriginHungtington's DiseaseSpastic Movement DisordersMultiple SclerosisNeuropathies (Diabetic nerve pain/Nerve pain like Fibromyalgia)Opioid Addiction/ Willingness to reduce opioid use (on Suboxone/Methadone as well)PTSD (Post-Traumatic Stress Disorder)Sickle Cell AnemiaTourette Syndrome
MEDICAL HISTORY (If doing on cell phone, turn phone sideways for this section!!)

We need to know a bit about your medical conditions, any doctors or specialists that you see, and surgeries that you may have had.
CHECK ANY MEDICAL CONDITIONS WHICH YOU MAY HAVE (You will be able to free type others below)

Allergies (Seasonal)Alzheimer's Disease/DementiaAsthmaAnxietyArthritisChronic Low Back PainChronic Neck PainCongestive Heart FailureCOPD/emphysemaChronic Kidney DiseaseClotting disorder (on blood thinner)DepressionDiabetesDiabetic NeuropathyDrug AddictionEnlarged prostateFibromyalgiaGastric bypassGoutHigh Blood Pressure (Hypertension)HeadachesHigh CholesterolHeart AttackHeart Rhythm Problem (Like Atrial Fibrillation, "A Fib"Kidney failure on DialysisKidney StonesLupusLeukemiaMigrainesRheumatoid ArthritisSeizure DisorderSleep ApneaStrokeTIA (Mini-strokes)
If you have been diagnosed with Sleep Apnea, do you use a CPAP, BiPAP, or oral appliance to treat your sleep apnea and is it controlled ?
PAST MEDICAL HISTORY - anything that wasn’t on the list above or that you want to add here)
MEDICATIONS with dose & frequency - if NONE then type "NONE" - ***MUST BE COMPLETED ****
Are you currently pregnant (for women only)? (PLEASE NOTE: If you are pregnant, a dispensary will notify our office and you will not be able to received medical marijuana until after you deliver your baby).

yesno
Are you currently on Methadone or Suboxone ?

YESNO
NAME OF PRIMARY CARE PHYSICIAN (No, we DO NOT contact them)
If NONE then write "NONE"
NAME OF ANY SPECIALIST PHYSICIANS YOU SEE, THEIR SPECIALTY, AND WHY YOU SEE THEM
* FOR EXAMPLE: DR SMITH - ORTHOPEDIC SURGEON - knee replacement; Dr Gray, Neurologist, MS. IF YOU DON'Y SEE ANY SPECIALISTS THEN TYPE "NONE"
ALLERGIES TO ANY MEDICATIONS/FOOD/LATEX (IF NONE, YOU MAY TYPE "NONE")
SOCIAL HISTORY

This helps to better understand you and your answers do NOT disqualify you from becoming a medical marijuana patient.
Have you ever used marijuana ?*

yesno
Do you currently use marijuana ? (THERE IS NO PENALTY FOR ANSWERING "YES")*

YesNo
If currently using marijuana, how often do you use/medicate ?
MARIJUANA USE -Please explain your experience with marijuana/medical marijuana. If it has helped with pain please explain how it helped. How much did you need to use. If it caused anxiety or your heart to race, please explain that as well. We ask this question because in some individuals, certain strains of medical marijuana can worsen anxiety/PTSD. (this question is optional)
Has marijuana ever caused a bad reaction ? (racing heart, anxiety, dizziness, paranoia)

YES, bad reactionNO, never bad reaction
What is your comfort level with cannabis /medical marijauana?

Very comfortable/knowledgableSomewhat comfortable/knowledgeableNot very familiar/knowledgeableNot at all familiar
ANXIETY (GAD-7 Questionnaire) - for those with anxiety

' OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY THE FOLLOWING: (make sure to answer each question with a red * mark before you click "SUBMIT" below)

Anxiety Form

	NOT AT ALL	SEVERAL DAYS	MORE THAN HALF THE DAYS	NEARLY EVERY DAY
(1) FEELING NERVOUS, ANXIOUS OR ON EDGE ?
(2) NOT BEING ABLE TO STOP OR CONTROL WORRYING ?
(3) WORRYING TOO MUCH ABOUT DIFFERENT THINGS ?
(4) TROUBLE RELAXING ?
(5) BEING SO RESTLESS THAT ITS HARD TO SIT STILL ?
(6) BECOMING EASILY ANNOYED OR IRRITABLE ?
(7) FEELING AFRAID AS IF SOMETHING AWFUL MIGHT HAPPEN ?

Calculation ( 5-9 mild anxiety) (10-14 moderate) (15+ severe anxiety)
CONSENT FOR TREATMENT AND MEDICAL CANNABIS USE
I am being evaluated for a physician's recommendation for Medical Cannabis. The physician will make recertification and recommendation based, in part, on the medical information I have provided. I hereby acknowledge that I have not misrepresented my medical condition to obtain this recommendation and it is my intent to use Medical Cannabis 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, sale/purchase and/or distribution of Medical Cannabis. I have been informed of and understand the following.
By typing your full name here, you acknowledge you have read the consent/liability forms above and you giving your consent for treatment. Typing your name here serves as your legal signature (REQUIRED FIELD).*
DateTime
THANK YOU FOR COMPLETING THIS INTAKE FORM.

When you click "SUBMIT" below, this will be transmitted to our office

****NEXT STEPS****

REGISTER WITH THE STATE TO GET YOUR PATIENT ID NUMBER!!! After submitting this form you can return to drsam420.com/scheduling to complete Step 2 and register with the state.

YOU WILL NEED TO PAY AT THE TIME OF YOUR CONSULTATION. If you are unable, please let Dr. Urick know so that we can schedule you for your telemed/phone consultation at a later date (office@drsam420.com)
WHEN YOU PRESS "SUBMIT" BELOW, IF YOU DID NOT COMPLETE FIELDS WITH A RED ASTERISK * , THE FORM WILL NOT GO THROUGH.

If you do not receive a pop-up message stating "THANK YOU FOR YOUR SUBMISSION" or a confirmation email, then it did not go through.
FOR PHYSICIAN USE ONLY BELOW
FOR PHYSICIAN USE/ DOCUMENTATION ONLY
Assessment/Diagnosis
PLAN
Electronically signed by Samuel Urick III, D.O.
Should be Empty:

PATIENT INTAKE AND MEDICAL HISTORY FORM

Patient Information

Reason for Medical Marijuana Evaluation

MEDICAL HISTORY (If doing on cell phone, turn phone sideways for this section!!)

SOCIAL HISTORY

ANXIETY (GAD-7 Questionnaire) - for those with anxiety

CONSENT FOR TREATMENT AND MEDICAL CANNABIS USE