PATIENT INTAKE FORM

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Name: ________________________________

Date of Birth: ________ / ________ / __

Gender:  Male  Female 

Address: ________ _______________

Town:  ________________________________________________________________ 

State: ________

Zip Code: __________ 

Last 4 of Social Security   __ __ __ __

Drivers License #: ________________________________

Exp. Date: ________________ 

Home Phone: ______________________________ 

Cell: _____________________________ 

Email: ____________________________________________________________

Primary Care Physician: ________________________________________________________ 

MMJ Certifying Physician: ______________________________________________________ 

Registered Caregiver (if applicable): ___________________ 

Phone #: ______________________ 

A Registered Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary. If you feel that you need a caregiver, please contact your certifying physician. Are you a veteran? 

(Please check one)  Yes  No *IF YES, PLEASE PROVIDE DOCUMENTATION* 

Last Name:_________

First Name :_________

1. Qualifying Condition: Patients 18 years of age or older:  

Amyotrophic Lateral Sclerosis  

Cancer 

 Cachexia

 Cerebral Palsy

 Complex Regional Pain Syndrome 

 Crohn’s Disease 

 Cystic Fibrosis

 Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication  of Intractable Spasticity

 Epilepsy

 Glaucoma

 Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable  Spasticity 

 Multiple Sclerosis

 Parkinson’s Disease

 Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency  Syndrome  Post Laminectomy Syndrome with Chronic Radioulopathy 

 Post-Traumatic Stress Disorder 

 Sickle Cell Disease  Severe Psoriasis and Psoriatic Arthritis 

 Terminal Illness Requiring End-of-Life-Care 

 Ulcerative Colitis  Uncontrolled Intractable Seizure Disorder  Wasting Syndrome Patients less than 18 years of age: 

 Cerebral Palsy

 Cystic Fibrosis 

 Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable  Spasticity  Severe Epilepsy

 Terminal Illness Requiring End-of-Life Care 

 Uncontrolled Intractable Seizure Disorder 

2. Tobacco use?         Yes  No 

    Alcohol use?         Yes  No 

    Cannabis usage?        Yes  No 

Please describe, if Applicable Have you had any negative cannabis usage effects? ____________________________________________________________________________________________________________________________________________________________________________________________

Have you had positive cannabis usage effects? ____________________________________________________________________________________________________________________________________________________________________________________________

(Please check all that apply)

Negative symptoms that I am currently experiencing: 

  Abdominal Pain / Cramping 

 Anxiety

  Depression 

 Difficulty Remaining / Falling Asleep

  General Pain 

 Headaches 

 Irritable or Hyperactive Bowels  Muscle Pain / Stiffness 

 Nausea / Vomiting 

 Nerve Pain 

 Ocular Pressure

  Opiate Dependence 

 Poor Appetite 

 Seizures 

 Tremors 

 Other _______________________________________________  

Health Conditions: 

Allergies: ____________________________________________________________________________________________________________________________________________________________________________________________

 Current Medication: Dosage: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. (PRIVACY POLICY AND PRACTICES STATEMENT  ) 

As a patient of (CAROLINA MMJ LLC)

:I understand I have rights to privacy of my protected health information as defined by the Health Insurance Portability Act of 1996. I have been made aware that upon request a copy of Caring Nature’s privacy policy is available to me. Caring Nature has made me aware of their right to change the terms of its Notice of Privacy Practice 

Patient Signature ________________________

Date ____________ 

Authorized Patient Representative _______________________________________________

What outcomes do you hope to experience using medical cannabis? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What method of medical marijuana do you prefer? 

(Please check all that apply) 

 Smoking 

 Vaporizing 

 Edibles 

 Oils 

 Tinctures 

 Concentrates 

 I am uncertain Type of medicine preferred? 

(Please check what applies) 

 High THC 

 Low THC 

 High CBD

  Low CBD 

 1:1 Ratio THC / CBD 

 I am NOT sure of my medical needs Preferred Medical Marijuana 

Products used currently, if any: ____________________________________________________________________________________________________________________________________________________________________________________________

Signature ______________ 

Date _____________  

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MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT

 5. Please be advised of the of the following: Possession or use of this product is unlawful outside of the State of Connecticut Cannabis-based medicine may have intoxicating effects and has not been analyzed or approved by the united states Food and Drug Administration and was produced without FDA oversight for health, safety, or efficacy. Medical cannabis may contain unknown quantities of active ingredients, impurities or contaminants. The efficacy and potency of cannabis may very widely depending on the cannabis strain and ingestion method. If the cannabis is smoked or vaporized: Smoking may be hazardous to your health. 

Cannabis smoke contains carcinogens and may lead to an increased risk of cancer, tachycardia, hypertension, heart attack, birth defects, brain damage, and lung disease. Initial Here Initial Here Initial Here Initial Here  If cannabis is eaten or swallowed: This product has been infused with cannabis or active compounds of cannabis. When eaten or swallowed, the intoxicating effects of this drug may be delayed by two or three hours or more. There is limited information on the side effects of using cannabis, and there may be associated health risks. 

Side effects of cannabis can include, but are not limited to: 

⁕ Memory loss 

⁕ Dry Mouth

 ⁕ Sexual Impotence 

⁕ Low blood pressure 

⁕ Confusion ⁕ Hunger/Loss of appetite ⁕ Cough/Bronchitis/Shortness of breath ⁕ Depression ⁕ Feelings of euphoria ⁕ Drowsiness/ Fatigue/Abnormal Sleep ⁕ Sedation/slower reaction time/Inability to  concentrate ⁕ Suppression of immune system ⁕ Anxiety/Nervousness ⁕ Irregular/Increased heartbreak ⁕ Numbness ⁕ Agitation ⁕ Poor physical condition ⁕ Dizziness/Impairment of motor skills ⁕ Dependency ⁕ Impaired vision ⁕ Laryngitis/Bronchitis/General Apathy ⁕ Headache/Nausea/Vomiting ⁕ Paranoia/Psychotic Symptoms Symptoms of cannabis overdose include, but are not limited to, nausea, vomiting, and disturbances to heart rhythm. This acknowledgment of disclosure is to advise you of risks and side effects of using cannabis medicines. It is important you review this document and discuss any questions you may have with the dispensary pharmacist. Please do not sign this agreement if you do not understand the information you have received or not comfortable with the risks that may be related to cannabis use or possession. Patient Signature ________________________________________ 

Date ______________ 

6. Initial Here_____

  MEDICAL CANNABIS PATIENT AGREEMENT I agree that the following statements are true and accurate: I am over 18 years of age and I am registered with and understand the requirements of the State of Connecticut’s medical marijuana program. I agree to strictly comply with the regulations, terms and conditions of the State of North Carolina's medical marijuana program. 

No cannabis obtained by me shall be used for any other purpose than as directed by my certifying physician. I understand cannabis is not to be resold, distributed, or used by any other person. I fully accept the responsibility in using cannabis and I certify I fully understand the potential risks related to the use of cannabis products.

 If I start using cannabis, I agree to tell my physician if I experience any one or more of the following: 

⁕ Start to feel sad or have crying spells 

⁕ Have changes in my normal sleep patterns 

⁕ Lose my appetite ⁕ Become more irritable than usual 

⁕ Become unusually tired 

⁕ Withdraw from my family and friends 

⁕ Lose interest in your usual activities 

In the event that I experience a severe adverse reaction, I am advised to immediately contact my physician. In the event that my physician is not available, I agree to call 911 for help, lie down and relax until help arrives.

I agree to tell my physician if I have ever had symptoms of schizophrenia, bipolar disorder, psychotic episodes or attempted suicide. I also agree to tell my medical professional if I have ever been prescribed or taken medicine for any of these problems. I acknowledge that the risks of using cannabis under these circumstances could be severe. 

I understand that my physician does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition. I am not pregnant, intending to become pregnant, or breastfeeding. I certify that I have read this document and declare that the information contained herein is true, correct and complete. 

Patient Signature: ______________

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FOR OFFICE USE ONLY -------------------------------------------- I was not able to obtain patient or patient representative signature. Employee name 

Date _______

Reason_________________________________________________________________________________________