BMore Hydrated Medical Cannabis Certification Intake Form
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
Identify as
Contact Info
Mobile Phone
Email
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Client Medical History
Have you been treated by a physician within the past year for any health conditions?
Characters:
0
/255
What is your physician's name?
Characters:
0
/255
Are you currently taking any medications?
Characters:
0
/255
Do you have any allergies to medications?
Characters:
0
/255
Have you had any surgeries in the past?
Characters:
0
/255
Is it possible that you might be pregnant?
Yes
No
Are you currently breast feeding?
Yes
No
What are your present complaints?
Characters:
0
/255
How did you hear about our service?
Characters:
0
/255
Please check off any conditions with which you suffer
Heart and Circulatory System
High Blood Pressure
High Cholesterol
Heart Disease
Chest Pain
Murmur
Palpitations
Stroke
Anemia
Bleeding Disorder
Swelling/edema
Genitourinary System
Urinary Retention
Kidney Disease
Bladder Disease
Prostate Disease/BPH
Menstrual Problems
Respiratory System
Asthma
Bronchitis
Pneumonia
Sinus Disease
COPD
Emphysema
Tuberculosis
Shortness of breath
Gastrointestinal System
Ulcer
Acid Reflux
Nausea
Vomiting
Constipation
Gall Bladder Disease
Neurologic System
Headaches
Migraines
Concussion
Dizziness
Numbness/Tingling
Epilepsy/Seizures
Weakness
Fainting
Balance Problems
Paralysis
Depression
Anxiety
Psychiatric Disorder
Multiple Sclerosis
Leber’s Hereditary Optic Neuropathy
Musculoskeletal System
Arthritis
Joint Problems
Bone Problems
Muscular Dystrophy
Other Chronic Medical Conditions
HIV/AIDS
Hepatitis
Diabetes
Cancer
Thyroid Disease
Medical Cannabis Qualifying Condition
What is your MMCC Number?
Characters:
0
/255
Please indicate if you suffer from any of these medical conditions:
Severe condition in which other medical treatments were ineffective
PTSD
Severe or chronic pain
Severe nausea
Glaucoma
Seizures or persistent muscle spasms
Severe weight loss as a result of a medical condition
Severe loss of appetite as a result of a medical condition
Wasting syndrome
Please provide additional information regarding this/these conditions such as onset, duration, symptoms, treatments attempted, and physicians whom you have been treated by for this/these conditions.
Review & Agree
HIPAA FORM
(Review Required)
You need to review and accept this before submitting
Consent Form
(Review Required)
You need to review and accept this before submitting
Payment and Cancelation Policy
(Review Required)
You need to review and accept this before submitting
Signature
×
Submit Form
×