First Name *

Last Name *

Phone *

Email *

Date of birth *

Gender *

Height *

Weight *

SS *

How did you hear about us? *

Emergency Contact Name and Phone Number *

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? *

If yes please explain (conviction) *

Are you currently attending or have been attending substance abuse or rehabilitation programs? *

If yes please explain (rehab) *

Do you smoke tabacco? *

If yes, how much and for how long? (tabacco) *

Do you consume alcohol? *

If yes, how do you drink, how often? (alcohol) *

If you a female, when was your last menstrual period? *

Are you currently pregnant? *

Are you Breastfeeding? *

Have you used Marijuana before? *

If yes when was the last time? In what form and how often? (marijuana use)

Which conditions are you requesting medical marijuana treatment for? *

Other (conditions) *

Did you bring supporting documentation to validate your condition? *

Any Allergies? *

If yes, please specify (allergies) *

Please indicate if you are taking any of the following? (Medication) *

Have you had any medical procedures/surgeries in the last 5 years? *

Please indicate if you have had any of the following surgeries *

Any other surgeries not listed above? *

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

Numbness of tingling *

Feeling hot *

Wobbliness in legs *

Unable to relax *

Fear of worst happening *

Dizzy or lightheaded *

Heart pounding/racing *

Unsteady *

Nervous *

Feeling of choking *

Hands trembling *

Shaky/unsteady *

Fear of losing control *

Difficulty in breathing *

Fear of dying *

Scared *

Indigestion *

Faint/lightheaded *

Face flushed *

Sum each of the above and write it below

Beck Anxiety Inventory Total Score *

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).

4. How SATTISFIED/DISSATISFIED are you with your CURRENT sleep pattern? *

0 - Very Satisfied

1 - Satisfied

2 - Moderately Satisfied

3 - Dissatisfied

4 - Very Dissatisfied

5. How NOTICEABLE to other do you think your sleep problem is in terms of impairing the quality of your life? *

0 - Not at all Noticeable

1 - A Little

2 - Somewhat

3 - Much

4 - Very Much Noticeable

7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY? *

0 - Not at all Interfering

1 - A Little

2 - Somewhat

3 - Much

4 - Very Much Interfering

Add the scores for all seven items and record below

Insomnia Severity Index *

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.)

a. The Federal Government’s classification of marijuana as a Schedule I controlled substance. *

The federal government has classified marijuana as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (I) a high potential for abuse; (2) no currently accepted medical use in treatment in the United State; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states, such as Florida, which have modified their state laws to treat marijuana as a medicine.

When in the possession of medical marijuana. The patient or the patient’s caregiver must have his or her medical marijuana use registry identification card in his or her possession at all times.

b. The approval and oversight status of marijuana by the Food and Drug Administration. *

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 federal standards, quality control, or other federal oversight. Marijuana may contain unknown quantities of active ingredients, which may vary in potency, impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.

c. The potential for addiction. *

Some studies suggest that the use of marijuana by individuals may lead to a tolerance to, dependence on, or addiction to 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 contact Dr. Martin.

d. The potential effect that marijuana may have on a patient’s coordination, motor skills, and cognition, including a warning against operating heavy machinery, operating a motor vehicle, or engaging in activities that require a person to be alert or respond quickly. *

The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. Driving under the influence of cannabis can double the risk of vehicular accident, which escalates if alcohol is also influencing the driver. While using medical marijuana, I should not dive, operate heavy machinery or engage in any activities that require me to be alert and/respond quickly and I should not participate in activities that may be dangerous to myself or others. I understand that if I drive while under the influence of marijuana, I can be arrested for “driving under the influence.”

e. The potential side effects of medical marijuana use. *

Potentials side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, imparement of short term memory, euphoria, difficulty in completing complex tasks, suppression fo the body’s immune system, may affect the production of sex hormones that lead to adverse effects, inability to concentrate, impaired motor skills, paranoia, psychotic symptoims, general apathy, depression and .or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of medical marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. Many medical authorities claim that use of medical marijuana, especially by persons younger than 25, can result in long term problems with attention, memory, learning, drug abuse, and schizophrenia.

There is substantial evidence of a statistical association between long-term cannabis smoking and worsening respiratory symptoms and more frequent chronic bronchitis episodes. Smoking marijuana is associated with large airway inflammation, increased airway resistance, and lung hyperinflation. Smoking cannabis, much like smoking tobacco, can introduce levels of volatile chemicals and tar i n the lungs that may raise concerns about the risk of cancer and lung disease.

I understand that using marijuana while consuming alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.

I agree to contact Dr. Martin if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience respiratory problems, changes in my normal sleeping pattern, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.

F. The risks, benefits, and drug interaction of marijuana. *

Signs of withdrawal can include: feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.

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 contact Dr. Martin immediately or go to the nearest emergency room.

Numerous drugs are known to interact with marijuana and not all drug interactions are known. Some mixtures of medications can lead to serious and even fatal consequences.

I agree to follow the directions of Dr. Marting regarding the use of prescription and non-prescription medication. I will advise any other of my treating physician(s) of my use of medical marijuana.

Marijuana may increase the rish of bleeding. Low blood pressure, elevated blood sugar, liver exzymes and other bodily systems when taken with herbs and supplements. I agree to contact Dr. Martin immediately or go to the nearest emergency room if these symptoms occur.

H. That the patient’s de-identified health information contained in the physician certification and medical marijuana use registry may be used for research purposes. *

The Department of Health submists a data set to the Consortium for Medical Marijuana Clinical Outcomes Research for each patient registered in the medical marijuana use registry that includes the patient’s qualifying medical condition and the daily dose amount and forms of marijuana certified for the patient.

PART B: Certification for medical marijuana in a smokable marijuana for a patient under 18 with a diagnosed terminal condition.

Check here if you are not a patient under 18 with a diagnosed terminal condition who will be receiving medical marijuana in a smokable form. After initialing here, complete part C. *

I am not a patient under 18 with a diagnosed terminal condition who will be receiving medical marijuana in a smokable form.

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.

Respiratory Health *

Cognitive and Psychological Development *

Researchers are still studying the long-term health effects of marijuana. Most people agree that marijuana use hurts adolescents more than adults. It is during the period of adolescence and young adulthood that the neural substrates that underlie the development of cognition are most active. Adolescence marks one of the most impressive stretches of neural and behavioral change with substantial protracted development in terms of both brain structure and function. As a result, cannabis and other substance use during this period may incur relatively greater interference in neural, social, and academic functioning compared to late developmental periods. There is moderate evidence of a statistical association between acute cannabis use and impairment in the cognitive domains of learning, memory and attention. There is limited evidence of a statistical association between sustain abstinence form cannabis use and impairments in the cognitive domains of learning, memory, and attention. There is limited evidence of a statistical association between cannabis use and impaired academic achievement and education outcomes. There is limited evidence of a statistical association between cannabis use and impaired social functioning or engagement in developmentally appropriate social roles.

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

Acknowledgement of contaminant risks. *

Smokable marijuana has infectious risks that are not present in processed products. Certain molds and mildews can contaminate marijuana plants during growing, processing, storage in dispensaries and in patient homes. These contaminants can pose health risks, particularly to those who are immunosuppressed due to their disease state treatments. While the State of Florida requires third party testing you should still inspect your product.

Respiratory Health *

Exposures to tobacco smoke and household air pollution consistently ranks among the top risk factors not only for respiratory disease burden but also for the global burden of disease. Given the known relationships between tobacco smoking and multiple respiratory conditions, one could hypothesize that long-term marijuana smoking leads to similar deleterious effects of respiratory health, and some investigators argue that marijuana smoking may be even more harmful than that of tobacco smoking. Information regarding health risks of 2nd and 3rd hand smoke to other household members. You should never smoke medical marijuana around other family members, especially children and any household guests. You should smoke outside to allow adequate ventilation and to mitigate the dangers of secondhand and thirdhand smoke to others. Marijuana should never be smoked inside vehicles or other small spaces that children will occupy even if the children are not present at the time the product is consumed.

Dangers of smoking marijuana in households where oxygen is in use. *

If you use oxygen or have others in your household who use oxygen you should not smoke marijuana or any other combustible material in the vicinity of where the oxygen is in use due to the risk of fire and explosion.

PART D: Must be completed for all medical marijuana patients

I have had the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe to be clarified. I acknowledge that Dr. Martin has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana. Dr. Martin also informed me of the risks, complications, and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that Dr. Martin informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits. Dr. Martin has explained the information in this consent form about the medical use of marijuana. *

I agree

MMJ Card Submission Date *

Signature *

Clear