Can we email you?
Are you currently in school?
Are you currently working?
Do you have any children?
If female, are you currently pregnant?
If female, do you plan on becoming pregnant?
If female, are you currently breastfeeding?
Have you been arrested or charged with a crime in the past two years?
Are you currently on parole or probation?
Have you been evaluated for medical marijuana use by another physician in the past?
Have you been denied a recommendation for medical marijuana use by another MD in the past?
Are you currently attending or have attended any substance abuse or rehabilitation program?
Do you ever have thoughts of suicide or have attempted suicide?
Are you providing us with any medical records?
Do you have a primary care physician?
Have you talked to you primary care provider about using medical marijuana?
Do you currently use tobacco?
Do you currently drink alcohol?
Do you currently use marijuana?
Do you currently use cocaine, methamphetamine, opiates, heroin or any other street drugs?
Are you allergic to any medications?
Have you ever been hospitalized?
Have you ever had surgery?
Please check any of the following problems anyone in your immediate family has.
Please check any of the following problems you have.