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 HOME web

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

HOME web