Patient Assessment Form - My-Grow
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2My-Grow
info@my-grow.ca
Patient Assessment Form
PATIENT INFORMATION
FIRST Name:
LAST Name:
Date of Birth:
Address:
Height:
Weight:
Gender:
Home Phone:
Email Address:
SKYPE User Name:
Cell Phone:
Licensed Producer (for interim supply):
MEDICAL HISTORY
Chief problem for which medical cannabis is being requested: (please be specific)
Are there any secondary medical problems:
List all your current medications including dosage:
List any medications you are allergic to:
Do any of your medications contain opiates? (Codeine, Morphine, etc.)
Do you use cocaine or other “street” drugs? ( ) No ( ) Yes
If yes, please list names and frequency:
Do you currently use cannabis for relief? ( ) Yes – smoke, vapor, edible, topical ( )No
How much cannabis are you hoping to obtain? (grams per day):
How often do you use cannabis?
(
) Everyday (
) Every other day
(
) 1-2 times per week (
) more than once a month ( )Other
Have you ever experienced an unpleasant /unwanted side effect of marijuana? (
)Yes ( )No
If yes, please describe:
Patient has been informed of possible side effects that may occur from use of marijuana (
)
Do you currently hold a prescription for medical cannabis? ( ) Yes ( ) No
If yes, when were you evaluated? ________________
Name of the physician that evaluated you? ________________________________________
Do you have or have you ever had any of the following medical conditions:
( )Asthma/Lung Disease ( )Hepatitis ( )Stroke ( )Kidney Disease (
)Thyroid ( )Heart Disease ( )Cancer
( )ADD/ ADHD ( )Substance Abuse ( )Depression ( ) MS ( )Schizophrenia ( )Hyper Tension
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Patient Signature:
Date:
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Parent category: Medical