CAL MED 420
www.calmed420.com
Patient Information
Name:
 
 Date:
 
Date of Birth:
 
 Age:
 
 Male:
 
 Female:
 
Address:
 
City:
 
 State:
 
 Zip:
 
Phone:
 
 Email:
 
How did you hear about us?
 
Primary Care Physician
Name:
 
 Address:
 
City:
 
 State:
 
 Zip:
 
Phone:
 
 Fax:
 
Have you had a medical recommendation from a doctor before? YES:  NO: 
Please Check All Reasons for Your Visit
-HIV/AIDS -GLAUCOMA -ANXIETY -NAUSEA
-LOSS OF APPETITE -MIGRAINE HEADACHES -BIPOLAR DISORDER -INSOMNIA
-WEIGHT LOSS -MUSCLE SPASM -HEADACHES -DEPRESSION
-PALPITATIONS -ADHD -DETOX PROGRAM -SEIZURES
-SEVERE DISABILITY -CHRONIC PAIN
Other:
 
Please check all symptoms that you have experienced in the past year
-HIV/AIDS -Cancer -Multiple Sclerosis -Hepatitis
-Diabetes -Anorexia -Cachexia( Wasting Syndrome) -Glaucoma
-Schizophrenia -Crohn’s Disease -Fibromyalgia -Vision or eye problem
-Asthma -Tuberculosis -Chronic Cough -Difficulty swallowing
-Fainting -Heartburn -Nausea/Vomiting -Chest Pain
-Coughing Blood -Heart Palpitations -High Blood Pressure -Stroke
-Fever -Migraine Headaches -Sinusitis -Bruise easily/Bleed
-Dizziness -Blood in Stool -Stomach Pain -Diarrhea
-Headaches -Constipation -Pain Urinating -Blood in Urine
-Increased Urination -Joint Pain -Kidney Disease -Swollen Ankles
-Numbness in Limbs -Muscle spasms -Chronic Pain -Seizures
-Toothache -Loss of Hearing -Insomnia -Anxiety
-Skin Rashes -Depression -Stress Disorder -Chemical Dependency
-Alcoholism
Other:
 
 
Describe your medical condition for which you need to use medical marijuana:
 
Describe when you noticed your first symptoms:
 
Who diagnosed and treated you for this condition?
Name of Physician/Chiropractor/Psychologist:
 
Address:
 
City:
 
 State:
 
 Zip:
 
Date of last visit:
 
Please list all treatments that you received for this condition.
-Medications -Physical Therapy -Chiropractic -Surgeries
-Homeopathy -Vitamins -Exercise -Acupuncture/Homeopathy
-Rehabilitation Programs -Massage Therapy -Injections -Psychiatric Counseling
Do you feel that this condition limits/interferes with your ability to live?
Please describe on a scale from 1 to 5.(1 NO ABILITY ... 5 NORMAL ABILITY):
WORK:
 
 EAT:
 
  
SLEEP:
 
 MOOD:
 
RELATIONSHIP:
 
 PHYSICAL ACTIVITY:
 
OTHER:
 
:
 
Do you feel that if this medical condition is not alleviated or treated, that it could cause serious harm to your safety, physical, or mental health? YES:  NO: 
Do you have allergies? YES:  NO: 
What are you allergic to?
 
Are/were you taking prescription medication? YES:  NO: 
Please list current prescription medications:
 
Are any of these prescription medication helpful? YES:  NO: 
If yes, then which prescription drugs most relieves your symptoms.
 
Please list all surgeries and dates of hospitalization:
 
Do you smoke tobacco? YES:  NO: 
If yes, how much per day/week/month:
 
Do you consume alcohol? YES:  NO: 
If yes, how much per day/week/month:
 
Have you ever been arrested for a controlled substance? YES:  NO: 
Are you currently on probation or parole? YES:  NO: 
Have you used Medical Marijuana to relieve your symptoms in the past? YES:  NO: 
Please describe:
How much do you consume per treatment, to feel relief from symptoms? Daily
 
 Weekly
 
 Monthly
 
What is your preferred method of use? -Smoke -Ingest -Vaporize -Topical Use
Any additional relevant information that you think may help the doctor in his/her evaluation.:
 
 
 
Are you now or were ever employed by City, State or Federal Government? YES:  NO: 
If yes, please explain:
 
 
 
Patient Consent of Verification

I understand that the Physician may be contacted to verify and/or authorize my status as their patient as well as
any prescription and/or recommendation that could be issued to the patient. My signature on this
statement authorizes the attending Physician or CalMed 420 to make such verifications or authorization.

This signed statement shall serve as a release for this purpose only. My HIPAA rights and other
patient/physician privacy rights as detailed under California State Laws will not be violated.

I understand if the physician requests medical records, follow up appointments, or prescription
medications, it is my responsibility and obligation to fulfill my attending Physicians request.
Patient Signature:
 
 Date:
 
Guardian/Caregiver:
 
 Date: