Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Medical Marijuana Patient History Form
Patient Name *
Date of Birth
____ / ____ / ________
Contact Phone
Qualifying Medical Conditions
Primary Symptoms
Previous Cannabis Use
Conventional Treatments Tried
Current Medications
| Medication | Dose | How often |
|---|---|---|
Preferred Consumption Method
Treatment Goals
Medical Marijuana Patient History Form template from formisoft.com. formisoft.com/intake-templates/medical-marijuana-history