HOW TO PREQUALIFY WITH THE MEDICAL MARIJUANA DOCTOR Pre-Qualification Questionnaire 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 Obsessive-compulsive disorder θ Impulse control disorder θ Insomnia θ Severe grief reaction θ Posttraumatic Stress 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 NAME _________________________________________ PRINT_________________________________________ PARADISE CLINIC PRINT OUT THIS FORM AND BRING IT TO OUR OFFICE AT YOUR APPOINTTMENT OR Call Now to get prequalified 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

Pre-Qualification Questionnaire

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 Obsessive-compulsive disorder

θ Impulse control disorder θ Insomnia

θ Severe grief reaction θ Posttraumatic Stress

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

NAME _________________________________________

PRINT_________________________________________

PARADISE CLINIC

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

Call Now to get prequalified 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