New Patient Health History
Please check any of the following symptoms that you have been experiencing:
Anxiety
Depression
Fatigue
Impaired strength or ability
Insomnia
Intractable Pain
Loss of appetite
Muscle atrophy
Nausea
Weakness
Weight loss
Other (please specify):
Please check any of the following medical conditions that you have been diagnosed with:
Other (please specify):
Multiple Sclerosis
AIDS
ALS
PTSD
Cancer
Crohn's Disease
Glaucoma
Hepatitis C
HIV positive
Parkinson's Disease
Please check any of the following medical conditions that you have been diagnosed with:
Please check any of the following aspects of your life that have been negatively impacted by your condition(s)
and/or symptom(s):
Emotional
Mental
Physical
Recreation
Social
Work
Other (please specify):
Focusing just on your most pressing health concern, please answer the following questions:
What are the current symptoms associated with this health concern?
What makes this condition better? What makes it worse?
Does this condition improve with marijuana use? Please explain.
Describe or explain the onset of this condition. How did it start?
What type of workup have you had for this condition (doctors seen, tests performed, etc.)?
What treatments have you tried? How well have they worked?
What treatments have you tried? How well have they worked?
If you are currently in pain, where is your pain?
Please tell us about your current medical provider (name of doctor or practice, or location)
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