HOW TO PREQUALIFY WITH THE MEDICAL MARIJUANA DOCTOR        AT PARADISE CLINIC


Pre-Qualification Questionnaire                                                      


Name___________________________________   Date______________


Do you suffer from:

θ                 AIDS

θ                 Anorexia

θ                 Arthritis

θ                 Cachexia/Wasting Syndrome

θ                 Cancer

θ                 Chronic Pain

θ                 Glaucoma

θ                 Migraine Headaches

θ                 Persistent Muscle Spasms

θ                 Seizures

θ                 Chronic Nausea

Do you suffer from: 

θ                 Asthma      

θ                 Parkinson Syndrome     

θ                 Epilepsy   

θ                 Multiple Sclerosis       

θ                 Depression

  Do you suffer from: 

θ       Chronic pelvic pain

θ       Severe menstrual cramps

θ       Severe premenstrual syndrome

θ       Painful intercourse

θ       Chronic abdominal pain

θ       Irritable bowel syndrome (IBS)

θ       Colitis

θ       Inflammatory bowel disease

θ       Interstitial cystitis

θ       Urinary incontinence

   Do you suffer from: 

θ       Anxiety                                    θ       Phobias                                                 

θ       Depression    θ       Situational stress reaction   

θ       Bipolar disorder                       θ       Attention deficit disorder          

θ       Manic-depressive disorder      θ       Severe grief reaction

θ       Obsessive-compulsive disorder

θ       Impulse control disorder  

θ            Posttraumatic Stress

θ      Insomnia


Do you suffer from: 


θ       Chronic sciatica

θ       Chronic back pain

θ       Chronic neck pain

  Do you suffer from:  

θ       Radiculopathy

θ       Neuralgia

θ       Neuritis

θ       Radiculitis

θ       Reflex sympathetic dystrophy syndrome

θ       Degenerative disc disease

  Do you suffer from: 

θ       Cerebral palsy

θ       Quadriplegia

θ       Parkinson's syndrome

θ       Tourette's syndrome

θ       Spinal cord injury

θ       Tremors

Do you suffer from any chronic disorder either medical or psychiatric that substantially limits your ability to conduct daily living activities?

Yes           No

Would your chronic disorder if not alleviated cause a serious harm to your safety or physical or mental health?

Yes           No

Have you had a non-satisfactory or poor response to your medical treatments to date regarding your medical condition?

Yes           No

Have you had a non-satisfactory or poor response to any prescription or over-the-counter medications to treat your medical disorder?

Yes           No

Do you have a primary care provider?

Yes           No

Have you discussed the option of medical marijuana with your primary care provider?

Yes         No  

Do you have a copy of your medical records that are pertinent to your serious illness, or chronic medical symptoms?

Yes         No

Are you familiar with the possible side effects associated with medicinal marijuana?

Yes         No

Are you familiar with the legalities associated with the use of medicinal marijuana?

Yes         No

Has marijuana provided relief of your condition till now?

Yes        No

Do you have a valid NEVADA Identification Card or Driver's License?

Yes           No




DATE ___________________





PARADISE CLINIC  


     

PRINT OUT THIS FORM AND BRING IT TO OUR OFFICE AT YOUR APPOINTMENT OR


Call Now to get pre-qualified by the Doctor for a Nevada State Marijuana Registry Card.   It’s FREE.




                                                                    702  255-MARA

                                                                                    (6272)





Compassionate  Care  and  Alternative  Treatment  with  Medical  Marijuana

                                 from the Marijuana Doctors at the Paradise Clinic



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