Written Certification Form Page 3
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4State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Reviewing Physician Written Certification Form
for Qualifying Patients Under 18 Years of Age
DEBILITATING MEDICAL CONDITION
The qualifying patient is diagnosed with and is currently undergoing treatment for the following debilitating
medical condition(s) (check all that apply).
cancer
spinal cord disease:
traumatic brain injury
seizures (including
damage to the nervous
(TBI) and post-
those characteristic
glaucoma
tissue of the spinal
concussion syndrome
of epilespy)
amyotrophic lateral
cord with objective
multiple sclerosis
positive status
sclerosis
neurological indication
for human
Arnold-Chiari
of intractable spasticity.
hepatitis C
immunodeficiency
malformation and
(including but not
virus (HIV)
Crohn's disease
Syringomelia
limited to arachnoiditis)
acquired immune
agitation of
spinocerebellar
Tarlov cysts
deficiency syndrome
Alzheimer's disease
ataxia (SCA)
hydromyelia
(AIDS)
myasthenia gravis
Parkinson's disease
rheumatoid
chronic inflammatory
hydrocephalus
Tourette’s syndrome
arthritis (RA)
demyelinating
polyneuropathy
residual limb pain
myoclonus
fibrous dysplasia
neurofibromatosis
nail-patella syndrome
dystonia
spinal cord injury
causalgia
muscular dystrophy
reflex sympathetic
syringomyelia
dystrophy, RSD
Sjogren's syndrome
severe fibromyalgia
(complex regional pain
lupus
cachexia/wasting syndrome
syndromes Type I)
Indicate underlying chronic or debilitating disease
interstitial cystitis
CRPS (complex
or medical condition:
regional pain
syndromes Type II)
____________________________________
Comments - Provide any additional information that would be useful in assessing this patient’s application to
the Medical Cannabis Patient Registry. Strike through this section if you do not have any comments.
Page 3 of 4
Printed by Authority of the State of Illinois
IOCI 15-164
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