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Patient registration form for medical cannabisNatural Wellness Center Patient Registration
Form for Medical Cannabis
First Name ______________________ Last Name_____________________ M.I. ______________ Date of birth ___/___/___ Sex: □ Male □ Female Physical Address ________________________________________________________________ City _________________________State _________________________Zip _____________ Telephone _______________________________Email ________________________________________ Mailing Address_____________________________________________________________ □ Other patient Referred by __________________________ Name of primary care Physician ___________________________ Telephone ______________________ (1) Please select all medical conditions that you have been, or are currently being treated for: Seizures, including those characteristic of epilepsy AIDS (acquired immune deficiency syndrome) Severe and persistent muscle spasms, including those characteristic of multiple sclerosis or (2) Please select any of the following tests performed: Reason for test: ______________________________________________________ Where was the test performed? _______________________________________ Provide name of doctor who ordered/requested test ______________________________ (3) Please list all surgical operations you have had (Past Medical History): (Operation performed; Hospital/Doctor; Year) (4) Please select all current medications you are taking, including over-the-counter medicines and supplements.
(5) Are you allergic to any medications? If yes, please let any medication(s):____________________________________________________________ (6) Provide detailed description of condition(s) (e.g. Severe pain from back injuries). Include when you first noticed symptoms.
_____________________________________________________________________________________________________ (7) Does this condition interfere with your ability to perform major life activities such as eat, sleep, work, and/or socialize? (8) Do you feel that your medical condition could cause serious harm or safety to your physical or mental health if the symptoms are not (9) Have you been evaluated, diagnosed, and/or treated for this condition? □ Yes □ No If yes, please provide the following: Physician’s name: _________________________________________________________________ Date of last visit _____________ (10) If not indicated above, please describe all treatments you have received for your current medical conditions such as medications prescribed, surgeries, physical therapy, acupuncture, homeopathy, chiropractic care or any other treatment. Also list any other information you believe is relevant to the doctor’s evaluation.
__________________________________________________________________________________________________________ (11) Do you currently use Cannabis to alleviate symptoms for your current medical condition? □ Yes □ No If yes, how does Cannabis provide relief for your symptoms? For example, relaxes muscle spasms, minimizes nausea, etc. ___________________________________________________________________________________________________________ (12) When did you realize that Cannabis relieved your medical symptoms? Age ___________ (13) How often do you use marijuana? □ Daily (14) Which method(s) do you exercise when you use Cannabis? □ Smoke □Vaporize (15) If recommended by the medical practitioner, do you plan on cultivating medical marijuana? □ Yes □ No If yes, please provide location of marijuana: Address ________________________________________________________ City ___________________________________________ Zip _____________ ******Background Information******
(1) Do you smoke cigarettes? □ Yes □ No How much? __ packs per day.___ If a former smoker, year quit? (2) Do you drink alcohol? □ Yes □ No If yes, how often: ________/month, and how much: _______drinks/sitting (3) Do you have a history of substance abuse? □ Yes The medical marijuana act prohibits use of medical marijuana in the workplace but is silent regarding the employer’s rights and duties regarding medical marijuana. It is suggested that employers treat medical marijuana like any other prescription drug that might impair ability, but is the discretion of the employer to allow medical marijuana use by its employees.
(5) Are you currently on parole or probation? □ Yes (6) Have you been convicted of a felony? □ Yes □ No ******ACKNOWLEDGEMENT******
▪I voluntarily consent to receive medical and health care services from Natural Wellness Center Consultants.
▪I understand that records relating to my care will be kept confidential, and that no information that would disclose personal identity will be released or printed, unless required by law.
▪I understand that despite Hawaii’s medical marijuana act, federal laws, rules and regulations, still prohibit the use, possession, cultivation or distribution of marijuana. Any federal laws or rules prohibiting the use of marijuana would likely override Hawaii state laws. Patients occupying rental units or subsidized housing who wish to use medical marijuana should seek legal guidance on this issue. ▪If the medical practitioner recommends use of marijuana for my medical condition(s), I consent to using marijuana only for the treatment of the condition(s) stated in the medical declaration.
▪I know that I may ask, at any time, any questions I have about my treatment. ▪I certify that the information on this form is correct to the best of my knowledge, and any medical history presented is also factual and complete.
▪I acknowledge that using cannabis as medicine has been explained to me to my satisfaction.
▪I have been informed of the potential risks of using cannabis with the medical practitioner. ▪I am aware that a Notice of Compliance has not been issued under the Food & Drug Regulations concerning the safety and effectiveness of cannabis as a drug. ▪ I am aware of the risks and benefits associated wit the use of cannabis are not fully understood, and that the use of marijuana may involved risks that have not been identified; and I accept those risks.
▪ I understand that the doctor will submit documents to the state of Hawaii which will include personal and health information only as required for the medical marijuana card.
▪ I understand the potential risks associated with an elevated daily consumption of marijuana, including risks with respect to the effect on my cardiovascular and pulmonary systems and psycho motor performance, risks associated with the long-term use of marijuana, as well as potential drug dependency.
▪ I accept all the aforementioned risks and will not hold The Natural Wellness Center Consultants responsible for any legal ramifications. Patient Name (print) ______________________________Patient Signature _____________________________ Date ___________________
Your Age: _____ First Name: _______________Last Name: ____________________Date: ____________ Phone: ____________________Cell Phone: ____________________ Date of Birth : ___________________ PHYSICIAN/S: ___________________________________________________________________________ When did your physician or nurse practitioner last examine your breasts? _____________________________ Date and