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MEDICAL CANNABIS PHYSICIANS OF FLORIDA

NEW PATIENT INTAKE FORM(S)
(This question is mandatory)
Name:
(This question is mandatory)
Date of Birth:
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FL Driver's License #:
Height:
Weight:
Social Security Number:
(This question is mandatory)
Phone No.:
(This question is mandatory)
E-Mail:
(This question is mandatory)
PERSONAL MEDICAL HISTORY:
Please list symptom(s) you experience:
Please describe previously listed symptom(s) frequency, severity and duration:
Symptom #1 Symptom #2
Severity Symptom #1
Symptom #2
Frequency Symptom #1
Symptom #2
Duration Symptom #1
Symptom #2
Please list all treatments you’ve tried, length of each treatment attempted, and their outcomes:
Please list all current medications, the dosage, and how many times a day you take them:
Please list any allergies:
(This question is mandatory)
Do you smoke cigarettes?
If yes, please type how many per day and for how many years in the comments
(This question is mandatory)
Do you drink alcohol?
If yes, please type how much and how often in the comments
(This question is mandatory)
Do you use recreational drugs?
If yes, please type the specific drug and how often in the comments
Are you currently, or have you ever used Marijuana before in the past?
Other medical problems not listed above:
List all prior surgeries and approximate dates performed:
List any other medical providers you see on a regular basis:
i.e. Cardiologist, Mental Health Provider, Kidney Doctor, Dentist, etc.