New Patient Intake Form Page 2
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1
2Are you taking any prescription medications or herbs? If yes, please list below:
Allergic to any medications? If yes, please identify:
Do you smoke: If yes, how much:
Do you drink alcohol: If yes, how much:
Currently use cannabis (marijuana) for your medical condition:
If yes, how many times:
daily
weekly
monthly
If yes, what is/are your preferred method(s) or cannabis use:
Inhaled:
vapor
smoke (joint)
smoke (pipe)
smoke (bong)
Ingested:
tea
capsules
butter/oil
tincture
baked goods
other
Suppository:
rectal
vaginal
Topical:
tincture
cream/ointment
poultice
parabath
DMSO
spray
How does cannabis compare with other medications you take?
Have you frequently experienced any of the following symptoms?
cough
diarrhea
fever
heartburn
nervousness
rectal pain
depression
seizures
vomiting
toothache
constipation
easy bleeding/bruising
skin rashes
heart palpitations
hearing problems
coughing blood
eye problems
stomach pain
swollen ankles
blood in stools
loss of appetite
difficulty swallowing
pain urinating
INITIALS: _________
Have you ever been exposed to asbestos, chemicals, poisons, or radiation (besides X-rays):
Are there health/medical problems that occur frequently in your family?
Have your brought with you today medical records or other documentation or items that
YES
NO
support the medical condition(s) identified above?
If NO, why not and when will these be obtained?
** PRINT THIS FORM AND BRING IT TO YOUR APPOINTMENT TO EXPEDITE YOUR VISIT **
Patient Signature: _________________________________
Doctor's Initials: ____
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