• Welcome to the Online Health Questionnaire.

    Please be patient as this form downloads.

  • 1. I hereby authorize WeedRecs, as owned and operated by PersonalRN, Inc. to use the Online Health Questionnaire as the initial component of a telehealth practice platform for the evaluation of my medical condition.

    2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

    3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

    4. I understand that my current insurance will not cover the fees associated with the telehealth service and I will be responsible for payment of the fee out of pocket.

    5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

  • Section 1

    Section 1

    You must be over 18 to continue.
  • GEOSTAMP
  • Location validation is intended to ensure our compliance with your State's cannabis laws.
  • Please respond YES if you're within 1-2 miles of the location shown.*

  • Format: (000) 000-0000.
  • What is your date of birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is your height and weight?*

  •  

  • Section 2

    Section 2

    Relevant Health Information
  • What is your biologic sex?*
  • Are you currently pregnant or is there a chance you could be?
  • When was your last menstrual period?
     - -
    2 digit month, 2 digit day, 4 digit year
  • To confirm, it is possible that you may be pregnant?
  • Are you actively trying to have a baby with your partner?*
  • To confirm, you are trying to conceive.
  • Do you use any birth control? If so, select from below. Otherwise you may skip this question.
  • Are you a parent to any children that live with you or are under your supervision?*
  • How old is your youngest child that lives with you?
  • Is the baby breast-feeding?
  • Research shows that a child exposed to THC through breast milk can have negative effects on the baby in infancy and later in childhood.
  • Who helps you with providing care for the daily needs of the baby?
  • Do you have any physical limitations that pose a challenge to your role as a parent?
  • Section 3

    Section 3

    Social History
  • Are you or a member of your household being actively investigated by Child Protective Services (CPS)?
  • Have you been arrested and convicted of a crime (or plead no contest) within the past 2 years?*
  • When were you arrested?
  • What were you arrested for?
  • Are you seeking aid or additional resources to assist in expunging or defending this crime?
  • Are you currently on parole or probation?*
  • Would you be in violation of your parole or probation if discovered that you were using cannabis or in possession of cannabis?
  • Do you have or have you in the past had a problem with substance abuse or addiction?*
  • Are you currently attending or have you ever attended any program for the treatment of chemical or drug abuse, dependence, or addiction?
  • Would you like to receive information or find out more about available resources for in your area for the treatment of chemical or drug dependance or addiction?
    • Click here to enter info regarding your treatment for CHEMICAL DEPENDANCE, such as cocaine, heroine, methamphetamine, etc. 
    • Was the care provided as an inpatient or outpatient basis?
    • Was it court-ordered or voluntary?
    • What was the name of the program and where was it located?
    • Approximately when did you enter the program?
       - -
      2 digit month, 2 digit day, 4 digit year
    • Approximately when did you leave the program?
       - -
      2 digit month, 2 digit day, 4 digit year
  • Section 4

    Section 4

    Social History (cont.)
  • In the past, have you been evaluated by a doctor for a medical marijuana recommendation?*
  • Were you ever denied a medical marijuana recommendation by a doctor?
  • Have you experienced marijuana recreationally in the past?
  • What is your preferred method to consume cannabis?
  • In the past 12 months, have you developed a tolerance to cannabis, meaning you need to take increased amounts of cannabis to feel the same effects?
  • In the past 12 months, have you spent a significant amount of time obtaining cannabis, using it or recovering from its effects?
  • Do you smoke cigarettes?*
  • How many cigarettes do you smoke daily?
  • Do you drink alcohol?*
  • Section 5

    Section 5

    Mental Health Screening
  • Do either you, your parents, your siblings, or children suffer from schizophrenia?*
  • Have you been feeling like your eyes, ears or brain has been playing tricks on you?
    • CLICK HERE FOR ADDITIONAL QUESTIONS YOU MUST ANSWER 
    • Who has received a diagnosis of schizophrenia?

    • In the past month, have you had the following thoughts, feelings, or experiences? Check “yes” or “no” for each item.

      Do not include experiences that occur only while under the influence of alcohol, drugs or medications that were not prescribed to you.

      If you answer “YES” to an item, also indicate how distressing that experience has been for you.

    • Do familiar surroundings sometimes seem strange, confusing, threatening or unreal to you?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you heard unusual sounds like banging, clicking, hissing, clapping or ringing in your ears?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do things that you see appear different from the way they usually do?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you had experiences with telepathy, psychic forces, or fortune telling?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you felt that you are not in control of your own ideas or thoughts?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you have difficulty getting your point across, because you ramble or go off the track a lot when you talk?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you have strong feelings or beliefs about being unusually gifted or talented in some way?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you feel other people are watching you or talking about you?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you sometimes get strange feelings on or just beneath your skin, like bugs crawling?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you sometimes feel suddenly distracted by distant sounds that you are not normally aware of?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you had the sense that some person or force is around you, although you couldn’t see anyone?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you worry at times that something may be wrong with your mind?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you ever felt that you don't exist, the world does not exist, or that you are dead?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you been confused at times whether something you experienced was real or imaginary?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you hold beliefs that other people would find unusual or bizarre?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you feel that parts of your body have changed in some way, or that parts of your body are working differently?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Are your thoughts sometimes so strong that you can almost hear them?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do you find yourself feeling mistrustful or suspicious of other people?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you seen unusual things like flashes, flames, blinding light, or geometric figures?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Have you seen things that other people can't see or don't seem to see?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • Do people sometimes find it hard to understand what you are saying?
    • When this happens, I feel frightened, concerned, or it causes problems for me.
    • How difficult have these problems made it for you at work, home or other people?
    • How long have you been aware of, or suffering from schizophrenia?
    • Do you take medication for schizophrenia?
    • Please include the dosage and how often you take medication(s) for schizophrenia.
    • In the past have you self-medicated with cannabis for treatment of your schizophrenia?
    • Was using medical cannabis effective?
    • Are you currently receiving mental health support and care on a regular basis from a psychiatrist or psychologist?
    • Will you allow us to contact your mental health specialist to discuss if cannabis has a role in your therapy?
    • Please enter your mental health specialist's contact information.
    • Do family members see things or hear things that other people do not?
    • In the past, have you received mental health support and care from a psychiatrist or psychologist?
  • Mental Health Screening

    Mental Health Screening

    Continued
  • We have asked if there is a personal or family history of schizophrenia. We would like to ask about other mental health issues, but as it pertains to only yourself. Do you have concerns about your mental health?*
  • Please select YES to the question below as you have designated mental health as the main reason you would like medical marijuana considered as a treatment.*
    • CLICK HERE TO PROCEED. 
    • Which condition(s) below does your mental health suffer from?

    • If you feel you may be dealing with bipolar disorder, please answer the following fourteen (14) questions.

      At any point in your life, has there ever been a period of time when you felt "you were not your usual self" and instead exhibited any of the traits below:

    • You felt so good or hyper that other people thought you weren't your normal self or were so hyper that you got into trouble?
    • You were so irritable that you shouted at people or started fights or arguments?
    • You felt much more self-confident than usual?
    • You got much less sleep than usual and found you didn't really miss it?
    • You were much more talkative or spoke much faster than usual?
    • Thoughts raced through your head or you couldn't slow you mind down?
    • You were so easily distracted by things around you that you had trouble concentrating or staying on track?
    • You had much more energy than usual?
    • You were much more active or did many more things than usual?
    • You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
    • You were much more interested in sex than usual?
    • You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
    • Spending money got you or your family into trouble?
    • If you answered YES to more than one of the above, have several of these ever happened during the same period of time?
    • How much of a problem did any of these cause you?
    • Have any of your blood relatives had manic-depressive illness or bipolar disorder?
    • Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

    • Bipolar Positive

      Based on your responses, it is likely you are experiencing symptoms of bipolar disorder. Living with these symptoms could be causing difficulty managing relationships and even the tasks of everyday life.

      • Bipolar disorder is an illness involving one or more episodes of serious mania and depression.  Sometimes a person might only experience symptoms of mania.  If a person only experiences feelings of sadness, this is considered depression.  During episodes of bipolar disorder, a person's mood can swing from excessively "high" and/or irritable, to sad and hopeless, with periods of normal mood in between. 
      • More than 2 million Americans suffer from bipolar disorder.
      • These results do not mean that you have bipolar disorder, but it may be time to start a conversation with someone you trust, a doctor, or mental health professional. 
      • This screen is not meant to be a formal diagnosis, but is a good way to identify if bipolar disorder is a possible problem. Diagnosis and care of mental health conditions can be difficult.
      • Having symptoms of bipolar disorder is different than having a bipolar disorder. In addition, symptoms of bipolar disorder can be caused by other mental health conditions, or other health problems. Only a trained professional, such as a doctor or a mental health provider, can make this determination.
  • Mental Health Screening

    Mental Health Screening

    Continued

  • If you feel you may be dealing with anxiety, please answer the following seven (7) questions.  

    Consider your response only for the past 2 weeks.

    Over the last 2 weeks, how often hae you been bothered by any of the following problems?

  • Feeling nervous, anxious or on the edge
  • Not being able to sleep or control worrying
  • Worrying too much about different things
  • Trouble relaxing
  • Being so restless that it is hard to sit still
  • Being easily annoyed or irritable
  • Being afraid, as if something awful might happen

  • If you feel you may be dealing with ADHD, please answer the following six (6) questions, rating yourself on each of the criteria shown using the scale ranging from NEVER to VERY OFTEN.

    Please respond based on how you have felt and conducted yourself over the past 6 months.

    Over the last 6 months, how would you conduct yourself with the following questions?

  • How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
  • How often do you have difficulty getting things in order when you have a task that requires organization?
  • How often do you have problems remembering appointments or obligations?
  • When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
  • How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
  • How often do you feel overly active and compelled to do things, like you were driven by a motor?

  • Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

    • A serious accident or fire
    • A physical or sexual assault or abuse
    • An earthquake or flood
    • A war
    • Seeing someone be killed or seriously injured
    • Having a loved one die through homicide or suicide.
  • Have you ever experienced this kind of event?
  • Have you had nightmares about it or thought about it when you did not want to?
  • Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
  • Were constantly on guard, watchful, or easily startled?
  • Felt numb or detached from others, activities, or your surroundings?
  • Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
  • How difficult have these problems made it for you at work, home, or with other people?
  • How long have you been suffering from {whichConditions}?
  • Do you take medication for {whichConditions}?
  • Please include the dosage and how often you take medication(s) for {whichConditions} .
  • In the past have you self-medicated with cannabis for treatment of your {whichConditions}?
  • Was using medical cannabis effective?
  • Are you currently receiving mental health support and care from a psychiatrist or psychologist?
  • Would you permit our doctor to contact your mental health specialist to discuss the benefits or risks of cannabis as part of your therapy?
  • Marijuana can aggravate certain aspects of mental health. While every patient is different, it is important to coordinate your psychiatric care with a specialist that knows you, in order to optimize your mental health. Please enter your mental health specialist's contact information.
  • Is there any additional information specific to your mental health which you would like to share?
  • Mental Health Screening

    Mental Health Screening

    Depression

  • If you feel you may be dealing with depression, please answer the following nine (9) questions.  

    Consider your response only for the past 2 weeks.

    Over the last 2 weeks, how many days have you been bothered by any of the following problems?

  • Little interest or pleasure in doing things
  • Feeling down, depressed or hopeless
  • Trouble falling asleep, or sleeping a lot
  • Feeling tired or having little energy
  • Poor appetite, or overeating
  • Feeling bad about yourself - or that you're a failure or have let yourself or your family down
  • Trouble concentrating on things such as reading the newspaper or watching TV
  • Moving or speaking so slowly that other people could notice
  • Thoughts that you'd be better off dead, or of hurting yourself

  • Are you in crisis?
     

    If you are in crisis, please call 911 or the National Suicide Prevention Hotline at 1-800-273-TALK or go immediately to the nearest emergency room.

     

    You may be at risk for harming yourself or someone else.

  • Are you feeling hopeless about the present or the future?
  • Have you had thoughts about taking your life?
  • Do you have an actual plan to take your life?
  • Have you attempted suicide in the past?
  • How difficult have these problems made it for you at work, home, or with other people?
  • How long have you been suffering from depression?
  • Do you take medication for depression?
  • Please include the dosage and how often you take medication(s) for depression .
  • In the past have you self-medicated with cannabis for treatment of your depression?
  • Was using medical cannabis effective?
  • Are you currently receiving mental health support and care from a psychiatrist or psychologist?
  • Would you permit our doctor to contact your mental health specialist to discuss the benefits or risks of cannabis as part of your therapy?
  • Marijuana can aggravate certain aspects of mental health. While every patient is different, it is important to coordinate your psychiatric care with a specialist that knows you, in order to optimize your mental health. Please enter your mental health specialist's contact information.
  • Section 6

    Section 6

    History of Present Illness
  • Are you seeking cannabis for treatment of menstrual discomfort?

  • The next question will provide a list of qualifying conditions for cannabis treatment in your state. Please select "Chronic Pain".

  • Please select the single main reason you would like medical marijuana considered as a treatment.*

  • Please identify the location of your pain, discomfort or spasm.
  • Which of the following symptoms have you experienced with your most recent exacerbation (flare-up)?

  • When were you diagnosed with cancer?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you cured of your cancer and in remission?
  • How long have you been aware of, or suffering from {pleaseSelect369}?*
  • Do you take medication for {pleaseSelect369}?*
  • Please include the dosage and how often you take medication(s) for {pleaseSelect369} .
  • In the past, have you self-medicated with cannabis for treatment of {pleaseSelect369}?*
  • Has using medical cannabis been effective for your condition?
  • Do you suffer from erectile dysfunction?
  • Do you take medication such as Viagra or Cialis for treatment of erectile dysfunction?
  • Section 7

    Section 7

    Past Medical History: Neurocardiovascular Disease
  • Have you had any prior history of the following illnesses? Please select all that apply.*
  • Image field 97
  • HOW ARE YOU TREATING YOUR ATRIAL FIBRILLATION (AF)? In order to lower the risk of having a stroke from AF, patients are often treated with "blood thinner" medications. These blood thinners include aspirin, Coumadin or warfarin, dabigatran.
  • WARNING! PLEASE READ BEFORE CONTINUING: 
  • Have you also suffered a stroke?
  • Please enter an exact date OR an approximate date of every stroke you've suffered. If you cannot recall, then check the "I don't remember" box.
  • Do you feel you are more emotionally sensitive or even suffer from depression since your stroke?
  • Have you had a heart attack?
  • Please enter an exact date OR an approximate date of every heart attack you've suffered. If you cannot recall, then check the "I don't remember" box.
  • Have you also suffered from heart failure?
  • Please enter an exact date OR an approximate date of every episode of heart failure you've suffered. If you cannot recall, then check the "I don't remember" box.
  • Do you know your total cholesterol level?
  • Do you know your HDL number (good cholesterol), your LDL number (bad cholesterol), and your triglyceride levels?

  • Your body needs good cholesterol to lower your risk of heart disease. This is one test where you want high numbers.

  • Your LDL is near normal. The average adult should maintain an LDL below 130 mg/dL.

  • Your LDL is borderline high. The average adult should maintain an LDL below 130 mg/dL.

  • Your LDL is high! The average adult should maintain an LDL below 130 mg/dL.

  • Your LDL is very high! The average adult should maintain an LDL below 130 mg/dL.

  • Your triglycerides are near normal. The average adult should maintain triglyceride levels below 149 mg/dL.

  • Your triglycerides are high. The average adult should maintain triglyceride levels below 149 mg/dL.

  • Your triglycerides are very high! The average adult should maintain triglyceride levels below 149 mg/dL.

  • Great job on keeping your total cholesterol in the desirable range, which is below 200 mg/dL.

  • Your total cholesterol is borderline high. Please follow up with your doctor to determine the best way to lower your total cholesterol below 200 mg/dL.

  • Your total cholesterol is high, which may double your risk of heart disease. It is important to follow up with your doctor to determine the best way to lower your total cholesterol below 200 mg/dL.

  • Please review the information below regarding blood pressure. Systolic blood pressure is the upper number and diastolic blood pressure is the lower number.

  • ATTENTION

    The DIASTOLIC blood pressure (bottom number) cannot be more than the SYSTOLIC blood pressure (top number).

    Please go back and correct your blood pressure entry.

  • Based on your blood pressure, you are  {totalRisk} times more likely to die of a stroke or heart attack.

     

  • Normal

    Under 120/80

    Congratulations on having optimal blood pressure numbers. Keep up the good work and stick with heart-healthy habits like following a balanced diet and getting regular exercise.

  • Elevated

    120-129/80

    Technically, you're not diagnosed with hypertension or high blood pressure...yet! People with elevated blood pressure are likely to develop high blood pressure unless steps are taken to control it.

  • HYPERTENSION STAGE 1

    130-139/80-89

    You need to make lifestyle changes.You may also want to ask your primary doctor to consider starting you on blood pressure medications based on your risk of a heart attack or stroke.

  • HYPERTENSION STAGE 2

    Over 140/90

    Please make an appointment to see your primary doctor, as you may need to be treated with a combination of blood pressure medications along with lifestyle changes.

  • Would you like to learn more about ways to continue keeping your total cholesterol at a healthy range?
  • Image field 353

  • The good news is that lifestyle changes AT ANY AGE are effective in helping you reduce cholesterol levels.

    • Exercise: Physical activity helps you lose weight and boosts your HDL levels. Aim for 30 to 60 minutes a day of moderate cardio.
    • Eat more fiber: Replace white breads and pastas with whole grains.
    • Eat healthy fats: olive oil, avocado, and nuts all have fats that won’t raise your LDL.
    • Limit cholesterol intake: Reduce the amount of foods high in saturated fat like cheese, whole milk, and high-fat red meats.
    • Quit smoking!!!!
  • Past History (continued)

    Past History (continued)

    Pulmonary Disease
  • Have you had any prior history of the lung disease listed below?*
  • Have you been hospitalized for your asthma?
  • Image field 1114
  • Have you ever required intubation and mechanical ventilation because of respiratory failure?
  • During the past 4 weeks, how much of the time did you feel short of breath?
  • Do you ever cough up any "stuff", such as mucus or phlegm?
  • Please select the answer that best describes you in the past 12 months. I do less than I used to because of my breathing problems.
  • Have you smoked at least 100 cigarettes in your entire life?
  • Image field 1137
  • Have you ever required intubation and mechanical ventilation because of respiratory failure?
  • How often do you use an inhaler?
  • Past History (continued)

    Past History (continued)

    Chronic Disease
  • Have you had any prior history of the following illnesses?
  • Do you need daily injections of insulin throughout the day?
  • What was your most recent blood sugar measurement? You may skip this question if you can't remember.
  • Do you currently experience any of the following symptoms?*
  • Do you have any allergies?*
  • Section 8

    Section 8

    You're almost done!
  • How did you hear about us?*
  • Please let us know who was kind enough to refer you to our service so that we may properly say thank you to them!

  • Can you please share their name, email and/or affiliate code (if you were asked to provide it when signing up)?
  • Can you please share the name and location of the dispensary or delivery service that was so kind to introduce you to us?
  • Where did you come across our advertisement?

  • Which social media platform did you hear about us?
  •    
  • Section 9

    Section 9

    The completed Online Health Questionnaire

  • Thank you for completing the Online Health Questionnaire by WeedRecs.

    You've provided us with a lot of personal health information, which will be organized and presented to your doctor in an easy-to-read document called the Patient Response Form (PRF).  The image below is an example of what the first page will look like:

    The format of the PRF will make it easier for your doctor to evaluate the large amount of information that you have provided and determine if medical cannabis would be of benefit.

    This document will be of value to your primary care or specialty physician, or any other healthcare provider that participates in your well-being.

    We are providing the opportunity to purchase an additional copy of the Patient Response Form to keep for yourself and share with your other healthcare providers.

    The extra copy can be purchased for $19.99 and will be sent to you as a PDF file by email.  Your PRF document will have no duplication restrictions, allowing you to share it with as many providers as you decide.

    Why should I have my own copy of the Patient Response Form?

    • The Patient Response Form (PRF) is customized & personalized to YOUR unique health needs.
    • Unlike other health forms that you've completed countless times in the past, your PRF doesn't have gaps and empty sections, which don't apply to you and your condition.
    • It will organize and present your medical information consistently so that you don't forget important issues, regardless of how complex your health status may be.
    • Your providers will appreciate the simplified and seamless transfer of your health data, allowing for more compelling interactions with your practitioner and better care for you.
  • Would you like to purchase your customized Patient Response Form PDF file for $19.99?

  • Please note this is NOT payment for your medical marijuana recommendation, which you will have to make later when your assessment has been completed.

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    • Click the button below to post this same Online Health Questionnaire that you experienced as a free link on your social media page.
    • Follow us on social media.

    • Thanks for completing the Online Health Questionnaire.

      Please watch this 1 minute video before clicking the SUBMIT button..

    • After clicking the submit button, you will be directed to a form that will allow you to schedule a meeting with a cannabis-specialty doctor in your area.

       

      In order to keep your medical information private, you will be asked to answer a few more questions for your doctor. Thank you for your patience with us during our expansion and the transitional period between WeedRecs and Heally.

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