Medical Marijuana Patient History Form
Form preview
Sign up and start customizing in minutes.
This medical marijuana patient history form is designed specifically for physicians and nurse practitioners providing medical cannabis evaluations and certifications in states with legal MMJ programs. The form captures comprehensive information about qualifying medical conditions such as chronic pain, PTSD, cancer, epilepsy, multiple sclerosis, and other debilitating illnesses approved under state cannabis laws. It documents the patient's history of conventional treatments tried, their effectiveness, side effects experienced, and reasons for seeking alternative cannabinoid therapy options.
The template includes detailed sections for assessing previous cannabis use (recreational or medical), consumption methods preferred, dosing experiences, therapeutic effects observed, and any adverse reactions. It helps practitioners determine appropriate cannabinoid profiles (THC, CBD, THC:CBD ratios), delivery methods, and starting doses based on the patient's medical history and treatment goals. The form supports compliance with state medical marijuana program requirements for documentation, assists in tracking therapeutic outcomes, and provides a foundation for ongoing patient education about safe and effective cannabis medicine use.
What's included
- State-qualifying medical conditions
- Symptom severity assessment
- Conventional treatment history
- Previous cannabis experience
- Consumption method preferences
- Therapeutic goals and expectations
- Contraindications screening
- Substance use history
- Mental health conditions
- Current medication interactions
Who uses this template
- Medical marijuana clinics
- Cannabis medicine physicians
- Integrative medicine practices
- Pain management centers
- Palliative care providers
All form fields
10 fields across 3 pages. Customize any field after signing up.
Start with this template
Sign up and start customizing the Medical Marijuana Patient History Form for your practice. Set up in minutes.
Related templates
Pain Management Intake Form
Pain management intake with pain mapping, numeric rating scales, functional assessment, opioid risk screening, and interventional procedure history. For pain medicine, spine, and chronic pain clinics.
Medical History Questionnaire
Detailed medical history form covering past conditions, current medications, allergies, surgical history, and family medical history. Essential for new patients and annual updates.
Substance Use Screening (CAGE-AID)
Substance use screening based on CAGE-AID adapted for drugs and alcohol. Includes frequency assessment, impact evaluation, and readiness for change. For primary care and behavioral health screening.