Welcome To The Holistic Clinic Paitent Form
 Personal Details
 *First Name   Middle Initial
 *Last name      
 *Date of Birth (MM/DD/YYYY)   *Age
 *Gender   Male  Female    
 Social Security Number   Driver Licence Number
 *Address   Address
 *Town/City   *Post Code
 *Country   *Phone Number
 *E-mail Address   *Confirm E-mail Address
 *Occupation   Emergency contact
  Best time to contact   Race
  Military    Yes  No Discharge
 Marital Status      
 Do you have Medical Insurance    Yes  No  If yes, who is your carrier
 *Who is your primary care physician or clinic
  *Are you seeing a Specialist / Consultant    Yes  No
  Do you receive a pension, insurance payment or compensation for illness    Yes  No
 
 Chief complaints
 *What is the main problem for which you seek evaluation on treatment today? (or    the main reason you currently use cannabis) i.e. nausea, anorexia, spasms, pain,    etc.?
 *When did this problem start?
 *When did you last see your doctor or a specialist about this complaint
  Date of Injury / Illness
  Have you been injured in traffic accidents
  Have you been injured in other accidents
  Have you had any fractures or dislocations
  Have you been injured after use of alcohol Yes  No
  Have you had a head injury Yes  No
 What types of treatments have you tried in treating your problem
 *Current prescription medications
 *Previous prescription medications
 Over the counter and herbal medications
 Do you have Allergies
 What Medication intolerance do you have
 
 Other drug use
 Tobacco   Yes  No Alcohol   Yes  No
 Caffeine   Yes  No Opiates/heroin   Yes  No
 Cocaine   Yes  No Amphetamines   Yes  No
 Ecstasy   Yes  No Lsd/psilocybin/peyote   Yes  No
 And any other medications you have sampled in the past
 *Please list any past medical conditions you have suffered
 *Please list any past surgeries you have had
   
  Cannabis use pattern
 At what age did you first use cannabis
 What is your preferred method of consumption
 Which type do you prefer
 How often do you use cannabis
 Estimate the average amount of cannabis you use per day?
 Has the amount of cannabis needed to control your symptoms changed over time?
 If changed, to what do you attribute the change
 How effective is cannabis in treating your condition?
 How does cannabis compare with your usual prescribed medicines in relieving your symptoms?
 Have you ever stopped using cannabis only to find that your symptoms return or  worsen? Yes  No
 If your symptoms disappear or are substantially reduced would you keep on using  cannabis? Yes  No
 Have you ever used synthetic THC (Marinol)? Yes  No
 Does the use of cannabis modify your use of other drugs Yes  No
 Does use of cannabis modify your use of alcohol Yes  No
 Do you use, or have you used an antidepressant (SSRI) and cannabis together Yes  No
 If yes, describe the effect of each. Antidepressant: Cannabis
 Describe bothersome adverse effects that you have to cannabis
 Are there other reasons for which you use cannabis?
 Has your cannabis use affected your relationship with your family
 Do you understand California’s proposition 215 medical use of marijuana initiative statute? Yes  No
 Are you on probation or parole Yes  No
 Do you have a pending cannabis case Yes  No
 Are you subject to workplace drug testing? Yes  No
 Would you like to be contacted for participation in cannabis clinical research  studies? Yes  No
 Is there any other information the doctor should be aware of?
 *Location of the Clinic You want to Visit .