PATIENT HISTORY

New Patient History

Date________________

Name ___________________________________________________

Age______Date of birth ____/_____/_______Social Security # ___ __ ____

Address: ________________________________________________________________________________

City_________________ State ____ Zip ___________

Home phone:________________________ Work phone: _________________________

Cell phone:__________________________

Email: __________________________________________

1. Please indicate if you have been diagnosed with any medical problems including diseases of the liver, kidneys, intestinal tract, nervous system, and etc. _______________________________________________________________________

_______________________________________________________________________

Heart Disease? Explain________________________________________________________________

2. ALLERGIES: _____________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Medication/Drug Intolerance: θ Yes θ 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

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

____________________________________________________________________________________________________________________________________________________________________________

NEW PATIENT HISTORY & INTAKE FORM

Paradise Clinic

702 255-MARA

(6272)

Date________________

Name ___________________________________________________

Age______Date of Birth ____/_____/_______Social Security # ___ __ ____

Drivers Lic # ______________________or Nevada ID Card # __________________

Address: ________________________________________________________________________________

City_________________ State ____ Zip ___________

Home phone:________________________ Work phone: _________________________

Cell phone:__________________________

Email: __________________________________________

_______________________________________________________________________

Heart Disease? Explain________________________________________________________________

3. Medication/Drug Intolerance: θ Yes θ 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

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

7. Please list any chronic or persistent medical symptoms that you have that if not alleviated could cause serious harm to your safety or physical or mental health:

8. 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:

9. List all current prescription medicines and how often you take them:

______________________________________________________________________________________________________________________________________________

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

11. 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:

________________________________________________________________________________________________________________________________________________________________

12. Additional Information: Provide any other information you believe is relevant to the Doctor’s evaluation

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___ Physician Review: _______________________

Date:___________

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 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)

Initial Here____

PRINT THIS AND BRING COMPLETED TO YOUR APPOINTMENT.

Compassionate Care and Alternative Treatment with Medical Marijuana

from the Marijuana Doctors at the Paradise Clinic:

Please fill out the Contact us Form so we can send you additional forms to bring to your appointment.

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