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Microsoft word - intake form.doc

Last name: ___________________________ First name: __________________________ MI: _____________Birth date: ____________________________ Age: _________ SS#: ____________ - __________ - ___________ and/or Driver’s License #: __________________________ Address: _______________________________________ City: ______________ State: _____ Zip: ________Home phone: ___________________ Work phone: __________________ Cell phone: __________________Fax: __________________________ Email: ____________________________________________________Best time to contact: ______________________________  anytime  morning  afternoon  eveningRace:  African  Asian  Hispanic  Caucasian  Native American  Pacific Is.  Others________Occupation(s): _____________________________________________________________________________Current employment: Emergency contact: (Name, Relationship, Phone) ________________________________________________________ DEMOGRAPHIC INFORMATION:
Birth order: Born  1st  2nd  3rd  4th  5th  6th  7th
Birthplace: ________________________________________________________________________________
Years of education:  <10  11  12  13  14  15  16  >16
Major or Area of Specialty: ___________________________________________________________________Occupation(s) / Other Training, Certifications: ____________________________________________________ Military:  Yes  No Branch of Service:  Army  Air Force  Marines  Navy  Coast GuardService in Viet Nam:  Yes  No Other: _______ Highest Rank: ____________ Discharge:  Honorable  Dishonorable  General  Medical  others Citations: _________________________________________________________________________________ Spouse / partner's name: __________________________ Spouse / partner's occupation: ___________________Living Situation:  house  mobile home  apartment  institution Household members: first name, age and relationship ______________________________________________ GENERAL INFORMATION:
Do you have medical insurance?
 MediCal  Medicare  HMO  PPO  Kaiser  None  Others:_________ Primary care physician or clinic, Name: ______________________________Phone: _____________________Address ______________________________________________ City _________________ Zip ___________Specialist / Consultant, Name and Location: ______________________________________________________Specialist / Consultant, Name and Location: ______________________________________________________Specialist / Consultant, Name and Location: ______________________________________________________Do you receive a pension, insurance payment or compensation for illness or injury? Have you named an agent to make health care decisions for you? TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
Chief Complaint(s):
What is the main problem for which you seek evaluation and treatment today (or the main reason you currently
use cannabis) i.e. nausea, anorexia, spasms, pain, etc.? _____________________________________________
When did this problem start?
 < 1 month
When did you last see your doctor or a specialist about this complaint?
Trauma or Injury Questions:
Date of Injury / Illness: ______________________________________________________________________
Have you been injured in traffic accidents?
 Yes  No Date(s): _____________________________ Have you been injured in other accidents?  Yes  No Date(s): _____________________________ Have you had any fractures or dislocations?  Yes  No Date(s): _____________________________ Have you been injured in an assault or fight?  Yes  No Date(s): _____________________________ Have you been injured after use of alcohol?  Yes  No Date(s): _____________________________  Yes  No Date(s): _____________________________ Check treatment modalities that you have tried in treating your problem:
 Medications
 Therapeutic injections  Physical therapy  Chiropractic Care  Acupuncture  Counseling Current Prescription Medications: List names, dosage, frequency of use, and how long taken
1. _________________________Dosage _____________________ Frequency ______________ Duration _____________________
2. _________________________Dosage _____________________ Frequency ______________ Duration _____________________
3. _________________________Dosage _____________________ Frequency ______________ Duration _____________________
Previous Prescription Medications: (relevant) names, duration, and reasons of stopping.
1. _________________________ ________________________________ ___________________________________________________________
2. _________________________ ________________________________ ___________________________________________________________
3. _________________________ ________________________________ ___________________________________________________________
Over-the-Counter and Herbal Medications: List products that you use or have used in the past for the condition for which
cannabis is used (intended), i.e. ibuprofen, aspirin, glucosamine, milk thistle.

Medication Intolerance:
 Yes  No Explain: _______________________________________ Explain: _______________________________________ OTHER DRUG USE:
Tobacco:  Yes  No
TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
Please the medication(s) that you have sampled in the past.Acetaminophen
Tylenol #3
Marijuana as Medicine
Prior to the usage of cannabis, sampling other analgesics may be beneficial in managing pain. Although U.S. law classifies marijuana
as a Schedule I controlled substance (which means it has no acceptable medical use), a number of patients claim that smoking pot has
helped them deal with pain or relieved the symptoms of glaucoma, the loss of appetite that accompanies AIDS, or nausea caused by
cancer chemotherapy. There is, however, no solid evidence that smoking marijuana creates any greater benefits than approved
medications (including oral THC) now used to treat these patients, relieve their suffering, or mitigate the side effects of their
treatment. Anecdotal assertions of beneficial effects have yet to be confirmed by controlled scientific research.

Some of the marijuana dangers include impaired perception; diminished short-term memory; loss of concentration and coordination;impaired judgment; increase risk of accidents; loss of motivation; diminished inhibitions; increased heart rate, anxiety, panic attacks,and paranoia; hallucinations; damage to the respiratory, reproductive, and immune systems; increase risk of cancer; andpsychological dependency. TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
FAMILY MEDICAL HISTORY (check the box most applicable to you)
M Gmother: Maternal Grandmother; M Gfather: Materal Grandfather; P Gmother: Paternal Grandmother, P Gfather: Paternal Grandfather Ages and health of brothers, sisters and children:_______ ____________________________________ _______ ____________________________________ _______ ____________________________________ _______ ____________________________________ _______ ____________________________________ _______ ____________________________________ PAST MEDICAL HISTORY
(check the box most applicable to you) Arthritis
Back and neck pain
Blood Disorders (anemia, abnormal clotting) Brain disorders (epilepsy, trauma, etc) Intestinal disorders (ulcers, colitis, IBS)
Kidney disease (cystitis, renal failure)  Liver disease (cirrhosis, hepatitis B or C)
Chronic pain, specify:
Lungs disease (asthma, emphysema)
Circulation (stroke, phlebitis, etc) Mental disorders (depression, anxiety, PTSD)
Dystonia (spasms, tremors, Parkinson's) Multiple sclerosis (neurodegenerative disease) Ear problems (tinnitus, hearing loss) Eating disorder (anorexia, bulimia)
Rheumatic disease (Lupus, Sjogrens, Reiters) Endocrine problems (thyroid, hormones) Skin disorders (psoriasis, eczema) Sleep disorders (insomnia, sleep apnea)
Substance abuse (tobacco, alcohol, other drugs)
Weight loss / gain
Number of pregnancies _________ Number of children _________ Children's present ages _______________
Are you pregnant now?
PAST SURGICAL HISTORY: Please list in chronological order surgeries and approximate dates.
1. _______________________________________________________________________________ Date: _____________________
2. _______________________________________________________________________________ Date: _____________________
3. _______________________________________________________________________________ Date: _____________________
TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
Symptoms: Check [X] symptoms you currently have or have had in the past year.
Appetite poor
WOMEN only
Loss of sleep
Loss of weight
Poor energy
High blood pressure
Disturbing feelings
Panic attack
Conditions: Check [X] conditions you currently have or have had in the past year.
Migraine Headaches
TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
At what age did you first use cannabis? _____ years old At what age did you discover that cannabis eased your medical symptoms? _____ years oldWhat were the circumstances? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  sinsemilla  whole plant  hashish  kief Methods of consumption:
 smoke ( joint  pipe  water pipe)  tea  capsules  butter  oil  tincture  baked goods  tincture  cream  ointment  poultice  para bath  DMSO How often do you use cannabis? 1 times per month  2 – 3/week  1/day  2/day  3/day  4/day  > 4/dayEstimate the average amount of cannabis you use per day? (large joint = 1 gram, 1/8 oz. = 3.5 gm) < 1 gram  1 gram  2 grams  3 grams  4 grams  5 grams  6 grams  others: ___ Would you use more if it were: 1) easier to obtain? Would you use more if it were: 2) cheaper to obtain?  Yes /  NoHow much more? Has the amount of cannabis needed to control your symptoms changed over time? much more  little more  about the same  little less  much less  variableIf changed, to what do you attribute the change: _____________________________________________________________________________________________________________________________________________How effective is cannabis in treating your condition? Much better (very effective)  Slightly better (somewhat effective) How does cannabis compare with your usual prescribed medicines in relieving your symptoms? Prescribed medicines work much better  Cannabis works a little better than prescribed medicines  Prescribed medicines work a little better  Cannabis works much better than prescribed medicines  Cannabis and prescribed medicines work best together Explain: __________________________________________________________________________________Have you ever stopped using cannabis only to find that your symptoms return or worsen? Explain: __________________________________________________________________________________If your symptoms disappear or are substantially reduced would you keep on using cannabis?  Yes  NoHave you ever used synthetic THC (Marinol)? If yes, compare effect of Marinol to natural cannabis: ___________________________________________ Does use of cannabis modifies your use of other drugs?  Yes  No Explain: _______________________ Does use of cannabis modify your use of alcohol?  Yes  No Explain: _______________________ Do you use, or have you used an antidepressant (SSRI) and cannabis together?  Yes  No If yes, describe the effect of each.
Antidepressant: ______________ Cannabis: _______________ Describe bothersome adverse effects that you have to cannabis: ______________________________________Are there other reasons for which you use cannabis? _______________________________________________Has your cannabis use affected your relationship with your family?  no change  slightly  a lot  not applicable TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
If so, please explain:____________________ Your religion: ____________________________ Your parent's religion: ____________________________ Hours of TV / Day: Preschool: _______ Grade school: ________ Middle school: ________ High school: _____Were you subject to abuse in home life Did you have reading or learning disabilities? Did you have behavior problems in school? Were you a bully or subject to bullying in school? Did you take prescription medication for behavior or Do you think the diagnosis applies to you? Did you begin regular alcohol or drug use in school? IMMUNIZATION RECORD: (please those those are most applicable to you)
 MMR (Measles/ Mumps/ Rubella) Polio, DPT (Diphtheria/ Pertussis/ Tetanus) Pneumococcal, Flu Shots Hepatitis A, Hepatitis B Meningococcus, Hemophilus Chicken Pox Others: ______________________________ How many years since your last: Tetanus: _______________How many years since your last: TB skin test: ____________ Chest X Ray ____________________________ SOCIAL QUESTIONS:
Do you suffer from household stress?
____________________________________________  birth control pills  condoms  others ______ MEDICAL LEGAL
Do you understand California's Proposition 215
medical use of marijuana initiative statute? Are you subject to workplace drug testing? Would you like to be contacted for participation in Is there any other information the doctor should be TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
Documentations:  medication bottles  paper  ______Patient is ___________ y/o [ asian  hispanic  afro-american  caucasian  others: ______________________ ] HPI:

[ days  weeks  months  years] [ days  weeks  months  years] [ days  weeks  months  years]  with  without improvement.
 with  without improvement.
 with  without improvement.
 nausea  gastritis  constipation  nausea  gastritis  constipation  nausea  gastritis  constipation  radiates to ______________________  unchanged  others: ______________________________________________________________________________________ DM  HTN  Hyperlipidemia  LBP  Leg Pain CVD  CAD CHF  Hepatitis  TB  HIV  DVT PSurgHx:
 unchanged1.____________________________________________________________________________________ Date ________________2.____________________________________________________________________________________ Date ________________  tobacco ______ pack /d ___________ years  alcohol ____________ oz. for _____ /d Pharmacological Management: (medication, dosage, frequency)  unchanged
1. ______________________ ____________________ _____________
3. ______________________ ____________________ _____________ 2. ______________________ ____________________ _____________ 4. ______________________ ____________________ _____________ Allergy:  NKDA
1._____________________________  rash  edema  convulsion  intubation2._____________________________  rash  edema  convulsion  intubation hgt. _______ ins. wgt. ________ lbs. BMI________ BP_____/_____ PExam:
General Appearance:
 pale  erythema  lesion  hair loss  swelling  itching  rash  red sclera  tearing  hypertrophic turbinates  immobile TM sclerae, pink conjunct. TM-nonerythem.  others:_____________________________________________________  JVD  thyromegaly  bruit  stridor  LAD  LAP   WNL CTA-B, vocal fremitus, resonant-B  wheezing  rale  rhonchi  crackles  WNL RRR, audible S1 S2, PMI 5th ICS MCL  tender [ guarded  rebound]  distended  HSM  visceromegaly  hyperactive BS  quiet BS  scar  HJR RUQ  RLQ LUQ LLQ  epigastrium  periumbilical  WNL warm DTR intact, capillary refill <2  edema [ pitting non-pitting]  clubbing  cyanosis  tenderness[ upper  lower]  decr. ROM  diminished pulse  cold  torturous varicosity  WNL FROM strength:[ 2  3  4  5 ]  numbness  tingling  burn-like  diminished vibration  tenderness [ cervical  thoracic  lumbar]  decr. ROM[ neutral  flexion  extension  side bending  rotation] Assessment:
 Anorexia 783.0
 Cancer 199.1
 Endometriosis 617.9
 Headache 784.0
 Irritable bowel 564.1
 PTSD 309.81
 Arthritis 715
 Carpal tunnel 354.0
 Epilepsy 345.9
 Hepatitis C 070.54
 Menst cramp 625.9
 Restless leg 333.99
 Cachexia 799.4
 Crohn's 555.9
 Extrapyram 333.9
 Herniated disc 722.2
 Movemt d/o 333
 Rheumatoid 714
 Anxiety 308.0
 Depression 311
 Fibromyalgia 729.1
 HIV 042
 Multiple sclero 340
 Spasticity 781.0
 Asthma 493.9
 Diab Mellitus 250
 Gastritis 535.5
 Hypertension 402.00
 Nausea Vomit 787.0
 Spinal injury 957
 Attention def 314.0
 Diab Neuro 250.60
 Glaucoma 365.9
 Insomnia 780.52
 Periph neuro 357
 Ulcer colitis 556.9
 Bipolar 296.8
 counsel pros/cons of cannabis  ask patient to inform PCP w cannabis  diet (fruits & vegs, no fat)  daily exercise 20 – 30 mins  oral fluid 6 – 8 glasses daily  smoking cessation  “exercise your legal rights” ______________________________________________________ Date: ____________________________________
Physician’s Signature
TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
I acknowledge that using cannabis as medicine has been explained to me and thatany questions that I have asked have been answered to my satisfaction.
I have discussed and been informed of the potential benefits and risks of using cannabis with the medical practitioner.
I know that I may ask now, or in the future, any questions I have about my treatment.
I voluntarily consent to receive medical and health care services from the TotalHealth Care Clinic.
I have been assured that records relating to my care will be kept confidential and thatno information will be released or printed that would disclose personal identity,unless required by law.
I am aware that a Notice of Compliance has not been issued under the Food andDrug Regulations concerning the safety and effectiveness of marijuana as a drug. Iunderstand the significance of this fact.
I consent to using marijuana only for the treatment of the symptom stated in themedical declaration.
I am aware that the benefits and risks associated with the use of marijuana are not fully understood and that the use of marijuana may involve risks that have not beenidentified; and I accept those risks.
I am aware that medical cannabis has not been approved under Federal Regulationsand I understand that medical marijuana has not been deemed legal under federallaw.
If the daily amount stated is more than five grams; I understand the potential risksassociated with an elevated daily consumption of marijuana including risks withrespect to the effect on my cardiovascular and pulmonary systems and psychomotorperformance, risks associated with the long-term use of marijuana, as well aspotential drug dependency.
I accept all the aforementioned risks and will not hold the Total Health Care Clinicor the Physician responsible for any legal ramifications.
I attest that the information on this form is correct and any medical history presentedto the doctor is also factual and complete.
Patient’s Signature_______________________________ TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
I attest that the information on this form is correct and any medical history presented or discussed with the doctor is also factual andcomplete to the best of my knowledge. I do not plan or intend to use my Physician’s recommendation for the purpose of illegallyobtaining medical cannabis. Solely for verification purposes, I authorize the Total Health Care Clinic to converse of my medicalcondition.
I understand that I must be a California State resident to obtain an approval or recommendation for the use of cannabis (medicalmarijuana) under California's Compassionate Use Act of 1996 (Health & Safety Code #11362.5).
I affirm that I have a serious medical condition that adversely affects my quality of life. I have found or am interested in findingwhether cannabis (medical marijuana) provides substantial relief and improvement in my condition.
I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may containunknown quantities of active ingredients, impurities and/or contaminants. I understand the potential risks associated with an elevateddaily consumption of marijuana including risks with respect to the effect on my cardiovascular and pulmonary systems andpsychomotor performance, risks associated with the long-term use of marijuana, as well as potential drug dependency. I am aware thatthe benefits and risks associated with the use of marijuana are not fully understood and that the use of marijuana may involve risks thathave not been identified.
In requesting an approval or recommendation for the use of this plant as medication, I assume full responsibility for any and all risks of this action.
I am advised that the cannabis (medical marijuana) smoke contains chemicals known as tars that may be harmful to my health. Recentresearch indicates that vaporizing cannabis may eliminate exposure to tar. Should respiratory problems or other ill effects beexperienced in association with its use, it should be discontinued and reported to the physician.
I was further advised that the use of cannabis (medical marijuana) may affect my coordination and cognition in ways that could impairmy ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resultingto me and/or other individuals as a result of my use of cannabis.
California's Compassionate Use Act of 1996, (Health & Safety Code #11362.5), provides for the possession and cultivation ofcannabis (medical marijuana) for the personal medical purposes of the patient with a physician approval or recommendation. It shouldbe made absolutely clear that the physician, staff and representatives of this practice are neither providing cannabis, nor are theyencouraging any illegal activity in my obtaining cannabis (medical marijuana).
I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medicinalcannabis treatment. I acknowledge that using cannabis as medicine has been explained to me and that any questions that I have askedhave been answered to my satisfaction. There are no claims about the medical efficacy of cannabis. The physician, staff, andrepresentatives are addressing specific aspects of my medical care, and, unless otherwise stated are in no way establishing themselvesas primary care provider. Should an approval be made for my medicinal use of cannabis, I understand that there is a renewal datespecified by the physician. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabisuse beyond the term of the approval. Furthermore, the undersigned, my heirs, assigns, or anyone acting on my behalf, hold thephysician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of cannabis.
I further understand that by signing below, I am authorizing the release of any part of this record, except for identifying information,for use in data analysis of cannabis treated patients.
Patient or Minor patient's parent or legal guardian Print Name: Last, First
TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338
Article 1: Agreement to Arbitrate: It is understood that any claim of malpractice, including any claim that health care services were unnecessary or
unauthorized or were improperly, negligently, or incompetently rendered or omitted, will be determined by submission to binding arbitration, and not
by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. The patient has the right to
seek legal counsel concerning this agreement, and has the right to rescind this agreement by written notice to the physician within ninety days after
the agreement has been signed and executed by both parties unless said agreement was signed in contemplation of this patient being hospitalized, in
which case the agreement may be rescinded by written notice to the physician within ninety days after release or discharge from the hospital or other
health care institution. Both parties to this agreement, by entering into it, have agreed to the use of binding arbitration in lieu of having any such
dispute decided in a court of law before a jury.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all patient claims that may arise out of or related
to treatment or services provided by the physician including any heirs or past, present or future spouse(s) of the patient in relation to all occurrence
giving rise to any claim. This agreement is intended to bind any children of the patient whether born or unborn at the time of the providers or
preceptorship interns who now or in the future treat the patient while employed by working or associated with or serving as a back-up for the
physician, including those working at the physician's clinic or office or any other clinic or office whether signatories to this form or not. All claims
for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates,
association, corporation or partnership, and the employees, agents and estates of any if them, must be arbitrated including, without limitation, claims
for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court proceeding by the physician to collect any fee
from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the
physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.
Article 3: Procedures and Applicable Law: A demand for arbitration must communicate in writing to all parties. Each party shall select an
arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties
within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall
pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved
by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. Either party
shall have the absolute right to bifurcate the issue of liability and damage upon written request to the neutral arbitrator The parties consent to the
intervention and joiner in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such
intervention and joiner any existing court action against such additional person or entity shall be stayed pending arbitration. The parties further agree
that the arbitration conducted pursuant to this Arbitration Agreement shall be final and binding. The prevailing party shall be entitled to reasonable
fees incurred due to the arbitration, including arbitration fees, counsel fees, witness fees, or other expenses incurred by the prevailing party.
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A
claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the
applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed
herein with reasonable diligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 90 days of signature and if not revoked
will govern all professional services received by the patient.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency
treatment) patient should initial here ____. Effective as of the date of first professional services.
If any provision if this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not beaffected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signaturebelow, I acknowledge that I have received a copy.

Patient or Patient Representative Signature Physician or Authorized Representative Signature Print Physician or Authorized Representative Name TOTAL HEALTH CARE CLINIC, 13050 East Valley Blvd, La Puente, Suite 202, CA 91746,, 877-420-3338


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