New History Forms

New Patient History

Paradise Clinic

702 255-MARA (6272)

Date________________

Name ________________________________________________

Age___ Date of Birth __/__/___ Social Security # ___ __ ____ Driver's Lic #_______________________ (or Nevada ID #)

Address: ________________________________________________________________________________

City_________________ State __ Zip _____ Marital Status: Married__ Divorced__ Single__ Separated__

Home phone:________________________

Work phone: ________________________

Cell phone:__________________________

Email: __________________________________________

Job:_________________________ Employer: ___________________________________________

Are you on Disability__ Medicare__Medicaid__ Veteran__How did you hear about us? patient referral__________________________ Google_______

news__Doctor referral_________________________________ Other__________________________________

I, herein, disclose that I am not directly or indirectly associated with any local, state or federal law enforcement agency. Initials ________

1. Check if you have Problems with Liver__ Kidneys__ Intestinal Tract__ Nervous System__Heart__ Lungs__ Mental___Other_________

2. ALLERGIES: yes_______________________________________________________________________________________________

3. Medication/Drug allergy: Yes NoExplain:

__________________________________________________________________________________________________________________________________________________________________________________________________

4. Please describe all surgeries you have had. Please list the dates, the reason, , the doctor or doctors who performed the surgery and the hospital where the surgery was performed.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Please check the appropriate box if you presently have problems with:

θ HIV / AIDS

θ Weight loss/anorexia

θ Arthritis

θ Cachexia

θ Cancer

θ Chronic Pain

θ Glaucoma

θ Migraine Headaches

θ Muscle Spasms

θ Seizures

θ Severe Nausea

θ Post traumatic Stress Disorder

6. Please list any chronic or persistent medical symptoms that you have that limit your ability to conduct life activities or cause harm to your safety or mental health:

7. Chief Complaint(s):

Describe all of your medical problems for which you seek evaluation and treatment today or the reason you use or would like to use medical marijuana.

Please include when you first noticed the symptoms and when you first received your diagnosis:

8. Current prescription medicines/Marijuana and how often you take them:

______________________________________________________________________________________________________________________________________________

9. Name, address, and DATE last seen by physicians (chiropractor, acupuncturist, etc) who takes care of you for your present problems:

10. Please describe ALL treatments that you have received to date for your current medical problems such as medications, surgeries, physical therapy, acupuncture, homeopathy, chiropractic care, hypnosis or other:

________________________________________________________________________________________________________________________________________________________________

11. Legal History

Are you on probation or parole? θ Yes θ No If yes, is it drug-related? θ Yes θ No

12. Do you have a pending cannabis case? θ Yes θ No

Have you eve been accused or arrested for drug sales or distribution of drugs or marijuana? θ Yes θ No

Are you being investigated at work for possible drug use? _________ Upcoming drug testing artwork?________

13. Have you ever had a medical marijuana recommendation or referral in the past? Yes? No? (circle)

Which state? _______ Have you ever been rejected for marijuana treatment? Yes? No?

14. Have you ever been prescribed Marinol (Dronabinol)? When _________ Physician's Name, Address and Phone: _______________________________________________________________________________________________________________________________________________________________________________________________________________

15. Emergency Phone number of family member, close friend or neighbor:

Name______________________________________________________________

Address____________________________________________________________

Phone #_____________________________________________________________

Patient Signature ___________________________________Date ___/__/____

Print_____________________________________________

YOUR PRIVACY IS IMPORTANT TO US.

Please indicate if you would like our calls to be discreet and private when leaving a message

Yes___ No Need___

Because your entire process of obtaining permission to use medical marijuana is in our hands and the Nevada Department of Health, you may be assured the utmost in Confidentiality. We care.

The Doctor promotes the safe and responsible use of medical marijuana. Please do not drive, use heavy machinery or work while impaired or risk the health or safety of others. You may require an adjustment period as with any mind/body altering medication in order to perform certain tasks. Proceed slowly and with caution if you are a first time user of medical cannabis.

You will build up a tolerance to medicinal marijuana with continued use. In order to be a responsible user of "prescription" medical marijuana you should familiarize yourself with the Nevada Medical Marijuana Program and Federal laws regarding marijuana.

THE LAW:

Admission into the Nevada Medical Marijuana Program doesn't diminish your responsibility to follow public health and safety laws: You may never drive, sail or fly under the influence of medical marijuana; you may never possess a firearm in public under the influence of medical marijuana; and you may not even go on an amusement park ride if you're under the influence of medical marijuana. (NRS 484.379, 488.400, NRS 493.130, NRS 202.257, NRS 455B.080)

I have read the possible side effects of using marijuana as medicine as presented by the doctor. I permit all forms of communication from the Clinic.

Initial Here _______

*******************************

Physician Review: _______________________ Date:___________

RELEASE OF LIABILITY Paradise Clinic702 255-MARA (6272)

I ___________________________________________________am applying for the right to use medical marijuana for the use specifically discussed with the Physician. I attest that I have been informed of the risks and discussed the risks of using medical marijuana with the Medical Practitioner.

I hereby release the Doctor, associates and Medical practice from professional or personal liability in connection with my using medical Marijuana or obtaining a Medical Marijuana Identification Card. I am aware that I must adhere to the statutes of Nevada and that Federal law prohibits the use marijuana which may result in severe penalties for use, cultivation, distribution or possession.

I further agree that the Doctor's duty is to evaluate my eligibility for medical marijuana and to obtain a recommendation letter if approved. It is my responsibility to get a State ID card if I chose to. I understand that my records are HIPPA protected and my information will not be shared unless required by Law. I agree to allow telephone, fax or mail verification of my participation.

I agree to not duplicate, share or alter my Doctor’s Recommendation. If lost, I must obtain a new letter from the Doctor to license my legal use of cannabis in the state of Nevada. I further agree to carry my Doctor's Recommendation and or my State Marijuana Card.

I will continue treatment with my personal Physicians and take my prescription medications as directed & monitor dose changes. I have been informed I may need less Pain, Blood Pressure and Diabetes Medicines.

I have been informed of side effects of marijuana and not to use while pregnant or nursing. I will follow up with this office. I permit all forms of communication including automated phone messages. If requested, I may have a copy of this document.

Signature_____________________________________

Print _________________________________________ Date_____

HIPPA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES at the Paradise Clinic and Methods of Communication Between You (patient) and Paradise Clinic and staff.

In general, the HIPAA privacy rule gives individuals the right to request on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative mean as sending correspondence to the individuals office instead of the individuals home. The Privacy Rule generally requires health care providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an author requested by the individual in person. I hereby acknowledge that I have read the Notice of Privacy Practices ('Notice') was given to me upon arrival at the Paradise Clinic.

For matters such as appointment reminders and other Protected Health Information, I wish to be contacted in the following ways (CHECK ALL THAT APPLY):

HOME TELEPHONE __IT IS OK TO CALL MY HOME PHONE. CELL TELEPHONE __ IT IS OK TO CALL MY CELL PHONE. WORK TELEPHONE __IT IS OK TO CALL MY WORK PHONE MAIL (USPS) ___Okay to send mail to my home address

Print Name ______________________________________ Date_________________

X______________________________________ Signature

Note: if patient is a minor, parents/legal guardian must read and sign above

RECORDS

REQUEST FOR RELEASE OF MEDICAL

Patient's Name:Last_________________________ First _______________ Middle _______________

DOB:________________Previous Names Used: ___________________________________________

Driver's License or State ID Card______________________________

_____________________________________ ___________ ____________________________________

PATIENT SIGNATURE PARENT OR GUARDIAN

___________________________________________

PARENT OR GUARDIAN

DATESIGNATURE OF

PRINT NAME OF

By Signing the above, I Hereby Authorize (print name and address of practitioner below):

NAME: __________________________________________________________________ ____

ADDRESS: __________________________________________________________________ _

CITY: ___________________________ STATE: _______________ ZIP CODE: _____________

PHONE:________________________________FAX: _____________________________________

TO RELEASE INFORMATION TO:

Paradise Clinic 3225 S. Rainbow Blvd. Ste.204 Las Vegas, Nevada 89146

FAX: (702) 255-6272

I request that copies of my medical records including, but not limited to, the following items be sent:

X Problem list/medication list (Summary only)X Hospital Discharge Summary

XHistory and Physical Exam__ Other ____________________________

Note:We do not need your entire medical records, just a summary of the Medical and/or Mental Health Problem list and a Medication List (this is usually 1-3 pages).

POSSIBLE SIDE EFFECTS OF MEDICAL MARIJUANA

Paradise Clinic (702) 255-MARA (6272)

“MEDICAL MARIJUANA” (MEDICINAL CANNABIS, CANNABIS, TETRAHYDROCANNABINOLS)

CONTRAINDICATIONS:

Hypersensitivity to tetrahydrocannabinol or dronabinol products hypersensitivity to sesame oil

PRECAUTIONS:

Cardiac disorders such as arrhythmias, cardiac ischemia (usually manifest as either angina or a heart attack), concomitant use of sedatives or other psychoactive drugs, elderly patients may be more sensitive to psychoactive effects, history of substance abuse, history of psychiatric illness.

Do not drive, operate machinery, or engage in hazardous activities. Do not use during pregnancy or lactation. COMMON ADVERSE EFFECTS:

Abnormal thinking, impaired perception, impaired judgment, loss of motivation, diminished short-term memory, loss of concentration, depersonalization, euphoria, anxiety, panic attacks, paranoia, confusion, hallucinations, depression, dizziness/vertigo, drowsiness, diminished inhibitions; impaired coordination, increased risk of accidents, dry mouth, nausea, vomiting, high or low blood pressure, irregular heartbeat, increased heart rate, and “red” flushing of skin

DRUG INTERACTIONS:

Ritonavir

PREGNANCY: CATEGORY C

Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Most prescription medications are classified in Category C.

BREAST FEEDING:

Potential risk; change in therapy or care plan may be advisable

AGE RESTRICTION:

Patients age 18 and older may qualify for the use of medical marijuana, however, this office will recommend only to patients 21 and older (extraordinary exceptions may apply with written parental consent.)

The Doctor has provided and/or discussed the side effects of Medical Marijuana, and has offered a

more comprehensive copy of the side effects of the medicinal use of cannabis.

PRINT NAME______________________________________

_________________________________________________

PATIENT SIGNATURE

DATE ____________

The Doctor will review all forms for your Consultation and Card.