CANNABIS CARE INTAKE FORM

********PATIENT INTAKE AND MEDICAL HISTORY FORM*************

DR SAM 420
OFFICE CLOSED JULY 14-18 FOR VACATION
FOR INDIVIDUALS WHO ARE PENNSYLVANIA RESIDENTS AGE 18 AND OLDER

IF YOU ARE UNDER 18, PLEASE STOP HERE.

• Payment for the consultation with Dr. Sam is due at the time of the scheduled consultation.

• Payment to the state Dept of Health is due AFTER Dr Sam has certified you.

• WHEN COMPLETING THE FORM, YOU WILL NEED TO FILL IN EACH FIELD MARKED BY AN ASTERISK *. Your submission is completed if a screen pops up after submission stating "THANK YOU FOR YOUR SUBMISSION" with a GREEN CHECK MARK.
Patient Name*

First NameMiddle NameLast Name
Guardian Name (If patient is unable to sign)

First NameLast Name
Birth Date*

MonthDayYear
Date
Todays Date

MonthDayYear
Date
Patient Information
ADDRESS MUST Match PA Driver License/Photo ID card - WHATEVER PENNDOT has on file for your address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*
Cell Phone
Patient E-Mail*
example@example.com
Current Occupation
retired/unemployed may be listed
Emergency Contact
IF WE ARE UNABLE TO CONTACT YOU, THIS NAMED PERSON HAS PERMISSION FOR US TO DISCUSS YOUR CERTIFICATION, MEDICAL CONDITIONS OR APPOINTMENT SCHEDULING. IF YOU DO NOT WISH TO LIST ANYONE PLEASE TYPE "NONE" IN THE FIELD ABOVE UNDER "EMERGENCY CONTACT"
Relationship to Patient
Emergency Contact Phone Number
Race
Did someone refer you/how did you hear about us? ((example: google, dispensary,
Is this INITIAL or RECERTIFICATION ?*
LIST PREFERRED TIME FRAMES for us to call AFTER 10am (MONDAY-FRIDAY). We will be calling from (724)257-2157.

PLEASE NOTE: WE CLOSE AT 430pm M-Th, and 2pm ON FRIDAY.

We will try to accomodate your preferred time frames

(**THIS IS NOT NECESSARILY AN EXACT APPOINTMENT TIME**)

If you list only ONE exact time we will call when we are free to call.
LIST SEVERAL PREFERRED DAYS AND TIMES FOR DR SAM TO CALL. IF YOU ONLY LIST ONE SPECIFIC TIME YOU ARE NOT GUARANTEED TO RECEIVE A CALL AT THAT TIME. *
PREFERRED TIME, NOT AN OFFICIAL APPOINTMENT
We do NOT conduct calls after 430pm M-Th, or after 2pm on Fridays (We are CLOSED Saturday-Sunday)
Reason for Medical Marijuana Evaluation
Please check the box next to the qualifying medical condition(s) for which you believe you are a candidate for medical marijuana.*

AnxietyAmyotrophic Lateral Sclerosis (Lou Gherig's disease)AutismCancer (or in remission)Ulcerative ColitisCrohn's DiseaseDamage to the Nervous tissue of the Spinal Cord (with spasticity)Epilepsy or Intractable SeizuresGlaucomaHIV/AIDSSevere Chronic/Intractable Pain of Neuropathic OriginHungtington's DiseaseSpastic Movement DisordersMultiple SclerosisNeuropathies (Diabetic nerve pain/Nerve pain like Fibromyalgia)Opioid Addiction/ Willingness to reduce opioid use (on Suboxone/Methadone as well)PTSD (Post-Traumatic Stress Disorder)Sickle Cell AnemiaTourette Syndrome
MEDICAL HISTORY (If doing on cell phone, turn phone sideways for this section!!)

We need to know a bit about your medical conditions, any doctors or specialists that you see, and surgeries that you may have had.
CHECK ANY MEDICAL CONDITIONS WHICH YOU MAY HAVE (You will be able to free type others below)

Allergies (Seasonal)Alzheimer's Disease/DementiaAsthmaAnxietyArthritisChronic Low Back PainChronic Neck PainCongestive Heart FailureCOPD/emphysemaChronic Kidney DiseaseClotting disorder (on blood thinner)DepressionDiabetesDiabetic NeuropathyDrug AddictionEnlarged prostateFibromyalgiaGastric bypassGoutHigh Blood Pressure (Hypertension)HeadachesHigh CholesterolHeart AttackHeart Rhythm Problem (Like Atrial Fibrillation, "A Fib"Kidney failure on DialysisKidney StonesLupusLeukemiaMigrainesRheumatoid ArthritisSeizure DisorderSleep ApneaStrokeTIA (Mini-strokes)
If you have been diagnosed with Sleep Apnea, do you use a CPAP, BiPAP, or oral appliance to treat your sleep apnea and is it controlled ?
PAST MEDICAL HISTORY - anything that wasn’t on the list above or that you want to add here)
MEDICATIONS with dose & frequency - if NONE then type "NONE" - ***MUST BE COMPLETED ****
FOR WOMEN ONLY - Are you currently pregnant? (PLEASE NOTE: If you are pregnant, a dispensary will notify our office and you will not be able to received medical marijuana until after you deliver your baby).

yesno
Are you currently on Methadone or Suboxone ?

YESNO
NAME OF PRIMARY CARE PHYSICIAN (No, we DO NOT contact them)
If NONE then write "NONE"
NAME OF ANY SPECIALIST PHYSICIANS YOU SEE, THEIR SPECIALTY, AND WHY YOU SEE THEM
* FOR EXAMPLE: DR SMITH - ORTHOPEDIC SURGEON - knee replacement; Dr Gray, Neurologist, MS. IF YOU DON'Y SEE ANY SPECIALISTS THEN TYPE "NONE"
ALLERGIES TO ANY MEDICATIONS/FOOD/LATEX (IF NONE, YOU MAY TYPE "NONE")
SOCIAL HISTORY

This helps to better understand you and your answers do NOT disqualify you from becoming a medical marijuana patient.
Have you ever used marijuana ?*

yesno
Do you currently use marijuana ? (THERE IS NO PENALTY FOR ANSWERING "YES")*

YesNo
If currently using marijuana, how often do you use/medicate ?
MARIJUANA USE -Please explain your experience with marijuana/medical marijuana. If it has helped with pain please explain how it helped. How much did you need to use. If it caused anxiety or your heart to race, please explain that as well. We ask this question because in some individuals, certain strains of medical marijuana can worsen anxiety/PTSD. (this question is optional)
Has marijuana ever caused a bad reaction ? (racing heart, anxiety, dizziness, paranoia)

YES, bad reactionNO, never bad reaction
What is your comfort level with cannabis /medical marijauana?

Very comfortable/knowledgableSomewhat comfortable/knowledgeableNot very familiar/knowledgeableNot at all familiar
ANXIETY (GAD-7 Questionnaire) - for those with anxiety

OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY THE FOLLOWING: (make sure to answer each question with a red * mark before you click "SUBMIT" below)

Anxiety Form

	NOT AT ALL	SEVERAL DAYS	MORE THAN HALF THE DAYS	NEARLY EVERY DAY
(1) FEELING NERVOUS, ANXIOUS OR ON EDGE ?
(2) NOT BEING ABLE TO STOP OR CONTROL WORRYING ?
(3) WORRYING TOO MUCH ABOUT DIFFERENT THINGS ?
(4) TROUBLE RELAXING ?
(5) BEING SO RESTLESS THAT ITS HARD TO SIT STILL ?
(6) BECOMING EASILY ANNOYED OR IRRITABLE ?
(7) FEELING AFRAID AS IF SOMETHING AWFUL MIGHT HAPPEN ?

Calculation ( 5-9 mild anxiety) (10-14 moderate) (15+ severe anxiety)
CONSENT FOR TREATMENT AND MEDICAL CANNABIS USE
I am being evaluated for a physician's recommendation for Medical Cannabis. The physician will make recertification and recommendation based, in part, on the medical information I have provided. I hereby acknowledge that I have not misrepresented my medical condition to obtain this recommendation and it is my intent to use Medical Cannabis only as needed for the treatment of my medical condition, not for recreational or non- medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of Medical Cannabis. I have been informed of and understand the following. I consent to email, text and or voicemail from the office of My Way Medical, LLC (Dr Sam 420) while understanding that these are not HIPAA compliant forms of communication necessarily. You also consent to receiving email/text/phone call follow ups in subsequently to send reminders about renewing your medical card until which time you can indicate you no longer wish to receive email/text/phone calls.
HIPAA INFORMATION RELEASE
By typing your full name here, you acknowledge you have read the HIPAA, consent/liability forms above and you giving your consent for treatment. You also understand that Dr Sam 420 cannot complete any forms for employment regarding medical cannabis use. Dr Sam 420 will also not complete FMLA forms - your primary care physician would need to handle that. Typing your name here serves as your legal signature (REQUIRED FIELD).*
DateTime
THANK YOU FOR COMPLETING THIS INTAKE FORM.

When you click "SUBMIT" below, this will be transmitted to our office

****NEXT STEPS****

REGISTER WITH THE STATE TO GET YOUR PATIENT ID NUMBER!!! After submitting this form you can return to drsam420.com/scheduling to complete Step 2 and register with the state. Until you are registered with the state, you will not hear from our office.

YOU WILL NEED TO PAY AT THE TIME OF YOUR CONSULTATION. If you are unable, please let Dr. Urick know so that we can schedule you for your phone consultation at a later date (office@drsam420.com)
I understand payment of $149 is due to Dr Sam at the time of the consultation. This fee is SEPARATE from the fee due to the PA Medical Marijuana Program. By signing below, I understand that the payment, as stated above is due at the time of the phone consultation with Dr Sam.*
FOR PHYSICIAN USE ONLY BELOW
FOR PHYSICIAN USE/ DOCUMENTATION ONLY
Assessment/Diagnosis
PLAN
plan: patient instructed to speak with pharmacist at dispensary to review any potential new medication interactions or if questions about particular strains sold at a particular dispensary.
Electronically signed by Samuel Urick III, D.O.
Should be Empty:

********PATIENT INTAKE AND MEDICAL HISTORY FORM*************

Patient Information

Reason for Medical Marijuana Evaluation

MEDICAL HISTORY (If doing on cell phone, turn phone sideways for this section!!)

SOCIAL HISTORY

ANXIETY (GAD-7 Questionnaire) - for those with anxiety

CONSENT FOR TREATMENT AND MEDICAL CANNABIS USE

PATIENT INTAKE AND MEDICAL HISTORY FORM*****