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Are you currently on probation?*

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Please select any of the following problems you have or have experienced since your last visit*

AnxietyDepressionSleep disordersChronic PainBack PainMigrainesHeadachesPanic attacksPTSDCancerEpilepsyAlzheimerHIV/AIDSGlaucomaMultiple-sclerosisParkinsonALS (Lou Gehrig’s)Crohn’sWeight lossNumbnessJoint painChest painSwelling lower ext.Shortness of breathConstipationNauseaMuscle SpasmsDiarrheaLoss of AppetiteStomach PainVomitingSwollen AnklesSkin RashHeart Burn or RefluxSeizuresEye ProblemsBlood in BowelsChillsTirednessLympha denopathyOther

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Attending or have attended any substance abuse or rehabilitation program?*

Medical Marijuana Treatment, please provide details is your current dosage and regimen effective for your medical condition?*

What would you describe your current usage as?

What side effects, if any, have you experienced due to marijuana treatment?

Are you experiencing any benefits from using Medical Marijuana compare to your previously medical treatment?*

Have experienced an adverse drug interaction with any prescription or nonprescription medication with medical marijuana?*

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Basic Info

Personal

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Fee charged after visit:

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