BMore Hydrated Medical Cannabis Certification Intake Form
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Relationship
Client Medical History
Have you been treated by a physician within the past year for any health conditions?
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What is your physician's name?
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Are you currently taking any medications?
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Do you have any allergies to medications?
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Have you had any surgeries in the past?
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Is it possible that you might be pregnant?
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No
Are you currently breast feeding?
Yes
No
What are your present complaints?
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How did you hear about our service?
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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
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COPD
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Acid Reflux
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Constipation
Gall Bladder Disease
Neurologic System
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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?
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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.
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