Are you the person seeking treatment?
Have you been evaluation to obtain medical marijuana in the past
Have you been convicted of a felony in the last 2 years?
Are you currently attending or have been attending substance abuse or rehabilitation programs?
Do you smoke tabacco?
Do you consume alcohol?
Are you currently pregnant?
Are you Breastfeeding?
Have you used Marijuana before?
Which conditions are you requesting medical marijuana treatment for?
Did you bring supporting documentation to validate your condition? (labs, CT scans, MRI, follow up, etc.)
Any Allergies?
Please indicate if you are taking any of the following?
Have you had any medical procedures/surgeries in the last 5 years?
Please indicate if you have had any of the following surgeries
The following are Medical Marijuana Acknowledgement of Disclosure and Informed Consent Forms. Please read each item and check the space provided to indicate that you understand and agree with the information regarding the risks and side effects of using Medical Marijuna.
Beck Anxiety Inventory
Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.
Guide: 0 - Not At All, 1 - Mildly but it didn't bother me much, 2 - Moderately, it wasn't pleasant at times, 3 - Severely, it bothered me a lot
Sum each of the above and write it below
A grand sum between 0 - 21 indicates very low anxiety. That is usually a good thing. However, it is possible that you might be unrealistic in either your assessment which would be denial or that you have learned to “mask” the symptoms commonly associated with anxiety. Too little “anxiety” could indicate that you are detached from yourself, others, or your environment.
A grand sum between 22 - 35 indicates moderate anxiety. Your body is trying to tell you something. Look for patterns as to when and why you experience the symptoms described above. For example, if it occurs prior to public speaking and your job requires a lot of presentations you may want to find ways to calm yourself before speaking or let others do some of the presentations. You may have some conflict issues that need to be resolved. Clearly, it is not “panic” time but you want to find ways to manage the stress you feel.
A grand sum that exceeds 36 is a potential cause for concern. Again, look for patterns or times when you tend to feel the symptoms you have circled. Persistent and high anxiety is not a sign of personal weakness or failure. It is, however, something that needs to be proactively treated or there could be significant implants to you mentally and physically. You may want to consult a counselor if the feelings persist.
Insomnia Severity Index
The Insomnia Severity Index has seven questions. The seven answers are added up to get a tidal score. When you have your tidal score, look at the ‘Guidelines for Scoring/Interpretation’ below to see where your sleep difficulty fits.
Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).
Add the scores for all seven items and record below
Total score categories: 0-7 = Noclinically significant insomnia; 8-14 = Subthreshold insomnia; 15-21 = Clinical insomnia (moderate severity); 22-28 = Clinical insomnia (severe)
Medical Marijuana Consent Form
A qualified physician may not delegate the responsibility of obtaining written informed consent to another person. The qualified patient, or the patient’s parent or legal guardian if the patient is a minor, must initial each section of this consent form to indicate that the physician explained the information and, along with the qualified physician, must sign and date the informed consent form.
This consent form contains three parts. Part A must be completed by all patients. Part B is only required for patients under the age of 18 with a diagnosed terminal condition who receive a certification for medical marijuana in a smokable form. Part C is the signature block and must be completed by all patients.
Part A: Must be completed for all medical marijuana patients. (Check each box to confirm you have read and understand each statement.)
PART B: Certification for medical marijuana in a smokable marijuana for a patient under 18 with a diagnosed terminal condition.
If the patient is under 18, has a diagnosed terminal condition, and will be receiving medical marijuana in a smokable form, please review and initial the remainder of Part B before completing Part C.
Part C: For certification of smoking marijuana as an appropriate route of administration for a qualified patient, other than a patient diagnosed with a terminal condition
PART D: Must be completed for all medical marijuana patients