• Denver | Westminster | Fort Collins | Longmont

    Greeley/Evans | Fort Morgan

  • By Appointment

PATIENT INFORMATION FORMS

TO OBTAIN A MEDICAL MARIJUANA CARD, YOU MUST HAVE ONE OF THE FOLLOWING CONDITIONS. (Check one or more)
NOTE: STRESS, ANXIETY AND DIFFICULTY SLEEPING ARE NOT RECOGNIZED BY COLORADO AS LEGITIMATE REASONS TO RECEIVE A MEDICAL MARIJUANA CARD!!
You experience symptoms how many times?
Your symptoms are:
How bad is your problem? (mild)
Your problems interfere with work/social activities:
If you experience pain, the quality of your pain is:
Initial Below
I have been given copies of the following:
We are establishing a physician-patient relationship to determine whether a recommendation for the safe use of medical marijuana can be made and NOT for any other purpose. You are advised to consult with your primary care provider at least once a year for re-evaluation of the diagnosis and treatment plan.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), you have certain privacy rights concerning your health care information. Under this law, your health care provider generally cannot give your information to your employer, or share your information for marketing or advertising purposes, without your written consent. It is important that you understand that your information can be used and shared in the following ways.
  • To Inform multiple health care providers who may be involved in your treatment directly and indirectly.
  • To inform your family, friends, relatives, or others that you identify, who are involved in your health care or heath care bills.
  • Threats to health and safety that involves you harming yourself or others
  • To make required reports to the police
  • To provide information about employees, to employers, regarding worker’s compensation
  • To obtain payment from third party payers.
I acknowledge that I have been offered a copy of my HIPPA privacy rights. And I agree to have this information released to my medical doctor. (This permission may be revoked at any time!)

MEDICATIONS

REVIEW OF SYSTEMS

Have You Had problems with any of the following organs or organ systems?
HEAD:
EYES:
NOSE:
THROAT:
CHEST:
HEART:
ABDOMEN:
GI:
URINARY:
INFECTIONS:
SKELETAL:
HEMATOL:
SKIN:
VASCULAR:
ENDOCRIN:
NEURO:
PSYCH:

CANCER

HABITS

Smoke
Coffee/Caffeine
Alcohol?
Drug Abuse

SURGICAL HISTORY

SURGERY
SURGERY

FAMILY HISTORY

Age
Medical Problems (If Deceased, put age and cause of death)
FATHER
MOTHER
CHILDREN

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