Medical Cannabis Clinics of Florida · 16244 S. Military Trail, Suite 150, Delray Beach, Fl., 33484 815 N Main Street, Kissimmee, FL 34744 3 I have used Cannabis (Marijuana) prior

16244 S. Military Trail, Suite 150, Delray Beach, FL 33484

815 North Main Street, Kissimmee, FL 34744

Medical Cannabis Clinics of Florida

Patient Information: Today’s Date: _________________

Name: _______________________________________

Date of Birth: ____________________

Last 4 Digits of SSN: ______________________ Marital Status: _______Gender: ______

Street Address: ___________________________________________________________

City/ State / Zip Code: ______________________________________________________

Phone # _________________________________ Cell #___________________________

E-mail Address: __________________________________________________________

Which of the following languages can you speak and/or understand? Please circle:

English Spanish Creole French Portuguese Hindi/Urdu other ______________

Ethnicity: Non- Hispanic/Latino _________ Race (circle ) Caucasian African-American Hispanic

Hispanic/Latino__________ Indian Oriental Other__________

Employer: _____________________________ Employer Phone No.: ____________

Primary Care Physician:

MMJ Authorized Physician: Doctor who qualified you for Medical Marijuana Program

Emergency Contact: _____________________ Contact Phone No.: ______________

Registered Caregiver: ________________ Phone No.: ____________________ A Registered Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary. If you feel that you need a caregiver,

please contact your qualifying physician.

MY STATE APPROVED DIAGNOSIS:

□ Amyotrophic Lateral Sclerosis (ALS) □ PTSD □ Cancer

□ Chronic Pain □ Crohn’s Disease □ A terminal condition

□ Epilepsy □ Glaucoma □ Multiple Sclerosis

16244 S. Military Trail, Suite 150, Delray Beach, FL 33484

815 North Main Street, Kissimmee, FL 34744

□ Parkinson’s Disease □ Positive for HIV or AIDS

□ Medical condition comparable to those listed above

HISTORY OF PRESENT ILLNESS:

Please describe your main problem or reason for making an appointment ___________________________

When did symptoms begin? ___________Have you been treated for this problem before? Yes No

If yes, please describe the treatment you received including dates:

______________________________________________________________________________________

PAST MEDICAL HISTORY PAST SURGICAL HISTORY (Please list)

PROBLEM / DATE SURGERY/YEAR

____________________________________ __________________________________________

___________________________________ ___________________________________________

____________________________________ ___________________________________________

CURRENT MEDICATIONS:

List all medications you are currently taking:(include non-prescription and occasionally used medicines).

Current medication Dosage/ Time taken

_______________________ ________________________

_______________________ ________________________

_______________________ ________________________

_______________________ ________________________

_______________________ ________________________

_______________________ ________________________

Please list all psychiatric medicines you have been prescribed in the past (including anti-depressants, anti-anxiety, anti-psychotics or

medications used to help you sleep).

Medication Name Dates How long you took it Side Effects

______________ _______ _________________ ___________________

______________ _______ _________________ ___________________

Have you ever been hospitalized for a mental/ psychiatric illness? If so, please list dates and hospital:

______________________________________________________________________________________

______________________________________________________________________________________

ALLERGIES ( List any medication, food or other allergies):

Do you have a pacemaker? Yes No

16244 S. Military Trail, Suite 150, Delray Beach, Fl., 33484

815 N Main Street, Kissimmee, FL 34744

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I have used Cannabis (Marijuana) prior to this visit: □ Yes □ No

If yes, please give name of doctor, date seen and condition for which cannabis was approved

Have you been evaluated and denied a medical marijuana recommendation? □ Yes □ No

If yes, please explain

Negative Effects Experienced using Cannabis (if applicable):

Positive Effects Experienced using Cannabis (if applicable):

Positive outcomes I hope to achieve using Medical Cannabis:



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FAMILY HISTORY:

Please use the space below to list all of your immediate family (parents, siblings, and children).

Under illnesses, please list serious illnesses or diseases, especially psychiatric/mental illness.

RELATIONSHIP AGE ILLNESS/ CAUSE OF DEATH __________________ ____ ________________________________________

__________________ ____ ________________________________________

__________________ ____ ________________________________________

CHILDREN:

__________________ ____ ________________________________________

__________________ ____ ________________________________________

__________________ ____ ________________________________________

SOCIAL HISTORY

Married _____ Divorced _____ Widowed _____

Number of Children _________________

Birth state and where you were raised: ___________________

Education Level: High School Graduate____ Some College_____ College Graduate _____

Degrees: ___________________________________________

Employment Status: Employed ______Unemployed ____ Retired_______ Student________

Smoking: Currently smoking______ Former smoker _____ Number of years: _______Never smoked ____

Alcohol History: Never drinks __________Currently drinks ________

Alcohol: approximate drinks per week: _________

Exercise: type: ____________________ frequency: ______________

Hobbies, interests: ____________________________________________

Are you currently driving? __________

Living Arrangements: With whom do you live? _______________________________

_______ Home

_______ Assisted living

_______ Nursing home

Is there any other information you want to make us aware of? ____________________________________



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PAST MEDICAL/ FAMILY HISTORY Please list any serious illness or ongoing medical problems since childhood. Include any surgical procedures:

Conditions Self Father Mother Siblings G-parent Other

Asthma

High blood pressure

Diabetes

Heart disease

Arrhythmia

Cancer

High cholesterol

Stroke/ TIA

COPD

Chronic bronchitis

Emphysema

Seizures

Dementia

Alzheimer’s disease

Parkinson disease

Huntington’s disease

Gastritis

Ulcers

Thyroid disease

Liver disease/ Hepatitis

HIV/ AIDS

Sinusitis

Kidney disease

Head/ Brain injury

STD

Reflux Esophagitis

Glaucoma

Macular Degeneration

Cataracts

Headaches/ Migraine

Miscarriages/ stillbirth

Vertigo

Tremors

Multiple Sclerosis

Birth/ Developmental Problems

Hypoxia

Depression

Anxiety Disorder

Schizophrenia

Bipolar Disorder (Manic Depression)

Obsessive Compulsive Disorder

ADD/ADHD

Learning Disability

Post Traumatic Stress Disorder

Other:



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REVIEW OF SYMPTOMS: Please check any of the following that pertain to you

Give dates, duration of symptoms and details when applicable.

CONSTITUTIONAL

□ Lack of energy or fatigue _______________________________________________________

□ Loss of appetite ___________________________________________________

□ Difficulty sleeping ____________________________________________________________

□ Awake early and can not return to sleep

□ Have trouble falling asleep

EYES

□ Eye pain ____________________________________________________________________________

□ Blurred or double vision _______________________________________________________________

□ Sensitive to glare _____________________________________________________________________

EARS/NOSE/THROAT/NECK

□ Problems with sense of smell ___________________________________________________________

□ Problems with taste ___________________________________________________________________

□ Problems with hearing _________________________________________________________________

□ Uses hearing aid _____________________________________________________________________

CARDIOVASCULAR

□ Chest pain __________________________________________________________________

□ At rest _______________________________________________________________

□ With activity __________________________________________________________

□ Swollen ankles _______________________________________________________________

□ Palpitations or heart racing _____________________________________________________________

□ High blood pressure ___________________________________________________________________

□ High cholesterol _____________________________________________________________________

RESPIRATORY:

□ Cough _____________________________________________________________________________

□ Asthma or wheezing __________________________________________________________________

□ Become short of breath when walking or with activity _________________________________

GASTROINTESTINAL:

□ Problems swallowing _________________________________________________________________

□ Burning in chest or stomach after meals or when lying down __________________________________

□ Constipation _________________________________________________________________________

□ Diarrhea ____________________________________________________________________________

□ Change in color of stool/ black or tarry stools? ______________________________________________

GENITAL/ URINARY:

□ Delayed ejaculation __________________________________________________________________

□ Difficulty holding in urine ______________________________________________________________

□ Difficulty maintaining an erection _______________________________________________________

□ Difficulty urinating ___________________________________________________________________

□ Frequent urinary tract infections _________________________________________________________

□ Loss of interest in sex _________________________________________________________________

□ Need to urinate more frequently _________________________________________________________

□ Pain when urinating ___________________________________________________________________

□ Pain with intercourse _________________________________________________________________

□ Trouble starting stream, dribbling or reduced stream _________________________________________



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MUSCULOSKELETAL:

□ Back pain __________________________________________________________________________

□ Difficulty standing up from sitting _______________________________________________________

□ Neck pain ___________________________________________________________________________

□ Other pain___________________________________________________________________________

□ Pain greater in the morning and decreases with activity _______________________________________

□ Stiffness or pain in joints _______________________________________________________________

NEUROLOGICAL:

□ Confusion __________________________________________________________________________

□ Difficulty finding your way ____________________________________________________________

□ Difficulty maintaining home ____________________________________________________________

□ Difficulty managing finances ___________________________________________________________

□ Difficulty speaking ___________________________________________________________________

□ Dizziness or fainting __________________________________________________________________

□ Feels dizzy when stands up _____________________________________________________________

□ Forgetfulness ________________________________________________________________________

□ Head trauma ________________________________________________________________________

□ Headaches or migraines _______________________________________________________________

□ Numbness or tingling in toes and fingers __________________________________________________

□ Problem with balance _________________________________________________________________

□ Recent fall or falls frequency ___________________________________________________________

□ Seizure or fits _______________________________________________________________________

□ Sleep problems such as loud snoring, gasping for breath, morning headaches,

daytime sleepiness or leg jerking ___________________________________________________

□ Tremor or difficulty writing ____________________________________________________________

PSYCHIATRIC

□ Anxious, restless ,or irritable ___________________________________________________

□ Crying Spells ______________________________________________________________________

□ Depression , persistent sadness or feeling blue _____________________________________

□ Difficulty concentrating ______________________________________________________________

□ Feelings of hopelessness or worthlessness ________________________________________________

□ Hallucinations ______________________________________________________________________

□ Hearing voices ______________________________________________________________

□ Loss of pleasure in life _______________________________________________________________

□ Paranoia __________________________________________________________________

□ Thoughts of hurting someone else _______________________________________________

□ Thoughts of suicide __________________________________________________________

ENDOCRINE:

□ Cold intolerance ____________________________________________________________________

□ Dry Skin ___________________________________________________________________________

□ Hair loss or coarse hair ________________________________________________________________

□ Heat intolerance _____________________________________________________________________

□ Hoarse Voice ________________________________________________________________________

□ Thyroid disease ______________________________________________________________________

□ Weight gain or loss ___________________________________________________________________



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HEMATOLOGICAL:

□ Anemia or low blood sugar _____________________________________________________________

□ Excessive bruising or bleeding __________________________________________________________

□ Recurrent infections or infections that will not go away _______________________________________

If you are female, please read the following carefully:

Are you pregnant or planning to become pregnant? (circle one) YES NO

Please be advised that as part of you consultation/evaluation and treatment you are responsible to avoid an accidental pregnancy.

Various medications, X-rays, CAT/MRI scans are contraindicated for pregnant women and may be very dangerous.

In complete understanding of the above and certifying that all information is true to the best of your knowledge, please sign below.

______________________________________________________________________________________

Patient Signature Print Name Date

Acknowledgement of Disclosure and Assumption of Risk Agreement



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This Acknowledgement of Disclosure and Assumption of Risk Agreement has been prepared to provide you

with information regarding the risk and side effects of using cannabis (also referred to as “marijuana”). It is

important that you read this information carefully and completely. Please discuss any questions you may have

with the dispensary pharmacist or your certifying physician. Once you have read and understand the attached

information, and have had any questions addressed to your satisfaction, please sign and date the

Acknowledgement of Disclosure and Assumption Risk Agreement.

Do not sign this Agreement and do not use cannabis if you have questions about or do not understand the

information you have received or are not comfortable assuming the risks that may be associated with cannabis

use or possession.

Risk and Side Effects of Cannabis Use

Possession or use of this product is unlawful outside of the State of Florida and prohibited by federal law. Patient Initials:

Cannabis may have intoxicating effects and has not been analyzed or approved by the United States Food and

Drug Administration (“FDA”) and was produced without FDA oversight for health, safety, or efficacy.

Cannabis may contain unknown quantities of active ingredients, impurities, or contaminants. Patient Initials:

The efficacy and potency of cannabis may vary widely depending on the cannabis strain and ingestion method. Patient Initials:

If cannabis is smoked or vaporized: Smoking may be hazardous to your health. Cannabis smoke contains

carcinogens and may lead to an increased risk of cancer, tachycardia, hypertension, heart attack, birth defects,

brain damage, and lung disease. Patient Initials:

If cannabis is eaten or swallowed: When products infused with cannabis or active compounds of cannabis are

eaten or swallowed, the intoxicating effects of this drug may be delayed by two or three hours or more. Patient Initials:

There is limited information on the side effects of using cannabis, and there may be associated health risks. Side

effects of cannabis can include, but are not limited to:

Memory loss

Anxiety/Nervousness

Dry mouth

Irregular/Increased heartbeat

Sexual impotence

Numbness

Low blood pressure

Agitation

Confusion



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Poor physical condition

Hunger/Loss of appetite

Dizziness/Impairment of motor skills

Cough/Bronchitis/Shortness of Breath

Dependency

Depression

Impaired vision

Feeling of euphoria

Laryngitis/Bronchitis/General Apathy

Drowsiness/Fatigue/Abnormal Sleep

Headache/Nausea/Vomiting

Sedation/Slower reaction time/Inability to concentrate

Paranoia/Psychotic Symptoms

Suppression of immune system Patient Initials:

Symptoms of cannabis overdose include, but are not limited to, nausea, vomiting, and disturbances to heart

rhythm. Patient Initials:

Notice of Compliance has not been issued under the Food and Drug Regulations (FDA) concerning the safety

and effectiveness of the medical use of marijuana as a drug. The scientific basis for medical use of cannabis has

not been established. There is little known information regarding how cannabis may or may not react with other

pharmaceutical or herbal medications. Patient Initials:

Some patients can become dependent on cannabis. This means they experience withdrawal symptoms when

they stop using cannabis. Signs of withdrawal symptoms can include feelings of depression, sadness or

irritability, restlessness or mild agitation, insomnia, sleep disturbance, unusual tiredness, trouble concentrating,

and loss of appetite. Patient Initials:

Some users can develop a tolerance to cannabis. This means higher and higher doses are required to achieve the

same symptom relief. Patient Initials:

The possibility exists that cannabis may exacerbate schizophrenia or bipolar disorder in persons predisposed to

those disorders. Patient Initials:

Woman should not consume cannabis products while planning to become pregnant, during pregnancy, or while

breast feeding, except on the advice of the certifying health practitioner, and in the case of breast feeding

mother, on the advice of the infant’s pediatrician. Keep out of the reach of children and pets. Patient Initials:

Using cannabis while under the influence of alcohol is not recommended. Patient Initials:

The use of cannabis may affect coordination, cognition, and judgement. While under the influence of cannabis,

do not drive, operate machinery, or engage in potentially hazardous activities. Patient Initials:



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Please note that cannabis will degrade over time. Patient Initials:

I certify that I have read the above Acknowledgment Disclosure and Assumption of Risk Agreement and I fully

understand the potential risks and side effects related to the use of cannabis as described above. In using

cannabis for medicinal use, I fully accept responsibility and assume the risks and side effects associated with its

use. I further hold harmless and release Center For Neuroscience of any liability related to any risks.

Patient Signature: Date:

Patient Name:



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Medical Marijuana Program Patient Agreement

I agree that the following statements are true and accurate:

I affirm that I have a qualified medical condition which may adversely affect my quality of life. Patient Initials:

I am over 18 years of age and I am registered with and understand the requirements of the State or Florida’s

medical marijuana program. Patient Initials:

I agree to strictly comply with the regulations, terms and conditions of the State of the Florida’s medical

marijuana program, including, but not limited to, ensuring that no cannabis obtained by me shall be used for any

other purpose than as directed by my certifying physician and such cannabis is not resold, distributed, or

otherwise possessed or used by any other person. Patient Initials:

I have been advised of the risks and side effects associated with using cannabis by my certifying physician and

have decided to assume such risks. Patient Initials:

If I start using cannabis, I agree to tell my physician if I experience any one or more of the following:

Start to feel sad and have crying spells

Have changes in my normal sleep patterns

Lose my appetite

Become more irritable than usual

Become unusually tired

Withdraw from my family and friends

Lose interest in my usual activities Patient Initials:

In the event that I experience a severe adverse reaction, I agree to immediately contact my physician. In the

event that my physician is not available, I agree to call 911 for help. Patient Initials:

I agree to tell my physician if I have ever had symptoms of schizophrenia, bipolar disorder, psychotic episodes

or attempted suicide. I also agree to tell my physician if I have ever been prescribed or taken medicine for any

of these conditions. I acknowledge that the risks of using cannabis under these circumstances could be severe. Patient Initials:

I understand that my physician does not suggest nor condone that I cease treatment of medications that stabilize

my mental or physical condition. Patient Initials:

I agree not to drive a car or operate dangerous or heavy machinery while using marijuana. Patient Initials:



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I am not pregnant, intending to become pregnant, or breastfeeding. Patient Initials:

I certify that I have read this Medical Marijuana Program Patient Agreement and declare that the information

contained herein is true, correct, and complete.

Patient Signature: Date:

Patient Name:



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Authorization for Medical Records and Reports

Date: _________________________________

To: ___________________________________

You, and any person associated with you, are hereby authorized to give to Center for Neuroscience or any

representative thereof any and all information which may be requested regarding my physical condition and

treatment rendered by you thereof, and if necessary to allow them, or any physician appointed by them, to

examine and X-Ray pictures/ CT or MRI scans/ electro-diagnostics of me, or records which may have

information regarding my condition or treatment.

Please Provide the Names and Phone Numbers of your physicians that you would like to have your records

forwarded :

PRIMARY CARE_________________________________________________

INTERNIST ______________________________________________________

CARDIOLOGIST__________________________________________________

PODIATRIST ____________________________________________________

OTHER __________________________________________________________

Patient’s Signature: _____________________________

Print Name: ___________________________________

DOB: _______________________________________

SS #: ________________________________________

Witness’ Signature: _____________________________



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E-Prescribing Consent Form

Patient’s Name __________________________

Center for Neuroscience is in the process of implementing ePrescribing:

�ePrescribing is a federally mandated initiative that requires all physicians prescribe in this

manner by 2011

�ePrescribing software sends prescriptions over the internet to your pharmacy in a safe, secure

way, through the same technology used by credit card companies. This helps protect the privacy

of your personal information.

�ePrescribing software also lets your doctor see important information - like drug interactions

and your prescription history.

Patient Consent:

I agree that Center for Neuroscience may request and use my prescription medication history

from other healthcare providers or third party pharmacy benefit payors for treatment purposes.

This consent form will be updated on an annual basis.

Please provide our office with your pharmacy name, address, phone number/ fax number

Pharmacy Name: ______________________

Address: ___________________________

___________________________

Ph# ________‐_________‐________

Fax#: ________‐_________‐________

_____________________________________ _______/______/20__

(Patient Signature) Date



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Medical Information Release Form (HIPAA Release Form)

Name: ___________________________________ Date of Birth: _____/____/_____

Release of Information

[ ] I authorize the release of information including the diagnosis, records; examination rendered to me and claims

information. This information may be released to:

[ ] Spouse________________________________________

[ ] Child(ren)______________________________________

[ ] Other__________________________________________

[ ] Information is not to be released to anyone

This Release of Information will remain in effect until terminated by me in writing.

Notice of Privacy Practices

I acknowledge that I have received the Notice of Privacy Practices.

Messages

Please call : [ ] my home [ ] my work [ ] my cell Number:__________________

If unable to reach me: [ ] you may leave a detailed message

[ ] please leave a message asking me to return your call

[ ] __________________________________________

Signed: ______________________________________ Date: ____/____/_____

Witness:______________________________________ Date: ___/____/______

Medical Cannabis Clinics of Florida · 16244 S. Military Trail, Suite 150, Delray Beach, Fl., 33484 815 N Main Street, Kissimmee, FL 34744 3 I have used Cannabis (Marijuana) prior

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