Patient History Questionnaire
Name _____________________________________________________ Male ❑ /Female ❑
Age __________ Date of Birth__________________ Birthplace _________________________
Current Address________________________________________________________________
(street address) (city) (state) (zip)
Phone ___________Cell phone __________ e-mail____________________________________
Occupation _________________ Unemployed___ Retired___ Disabled___Student/Where? ________
Chief Complaint:
List the medical problems for which you use or would like to use cannabis (i.e. nausea, pain, sleep, etc.)
_____________________________________________________________________________________
Medical History: ( ✓ check box if you now have, or have ever had any of the problems listed)
❑ Arthritis (OA, RA, other)
❑ Back or neck pain
❑ Blood disorders (anemia, abn. clotting)
❑ Brain disorders (epilepsy, trauma, etc)
❑ Bladder (cystitis, neurogenic)
❑ Cancer, specify:
❑ Chronic pain, specify:
❑ Circulation (stroke, phlebitis,etc)
❑ Diabetes
❑ Dystonia (spasms, tremors,
Parkinsons)
❑ Ear (tinnitus, hearing loss)
❑ Eating disorder (anorexia, bulimia)
❑ Endocrine (thyroid, adrenal, hormones)
❑ Eye (glaucoma, cataracts, macular deg)
❑ Genital / GYN problems
❑ Headache / Migraine headache
❑ Heart disease
❑ Herpes / Herpes zoster (shingles)
❑ High blood pressure
❑ HIV / AIDS
❑ Intestinal disorders (ulcers, colitis, IBS, reflux)
❑ Kidney disease (stones, renal failure)
❑ Liver disease (cirrhosis, hepatitis)
❑ Lung disease (asthma, emphysema, COPD)
❑ Mental health disorders (see below)
❑ Multiple sclerosis
(neurodegenerative disease)
❑ Prostate disease
❑ Rheumatic disease (Lupus, other autoimmune disease)
❑ Skin disorders (psoriasis, eczema, pruritis)
❑ Sleep disorders (insomnia, sleep apnea, restless legs)
❑ Substance abuse (see below)
❑ Weight loss / gain
 Other______________________
Mental Health History:
Have you ever been diagnosed with any of the following? (enter approximate age or date)
ADD or ADHD______ Anger______ Anxiety______ Bipolar disorder______ Brain trauma_______
Dementia______ Depression______ Mood disorder______ PTSD______ Schizophrenia________
Reproductive History (females):
# of pregnancies _____ # of children ______ Currently pregnant? Yes / No Breastfeeding? Yes / No
Surgical History: Please list any surgeries and approximate dates
_______________________________________
_______________________________________
_______________________________________
_______________________________________

Healthcare Information:
Name, location, phone of your healthcare professional (physician, chiropractor, therapist, etc)
___________________________________________________________________________
Time of last visit?______________ Have you talked to your doctor about cannabis? Yes / No
Current prescription medications (Or supplements, herbal medications, etc.): Please list below
1. ___________________________ Dosage ________ Frequency ________ Duration ________
2. ___________________________ Dosage ________ Frequency ________ Duration ________
3. ___________________________ Dosage ________ Frequency ________ Duration ________
4. ___________________________ Dosage ________ Frequency ________ Duration ________
Lifestyle and Habits:
Substance Use - Do you currently use?
Tobacco Yes/ No # cigarettes/day____, for how long____, Prior use? Yes/ No, Quit date? _____
Alcohol Yes/ No # of drinks/ week___, for how long____, Prior use? Yes/ No, Quit date? _____
Cocaine / Methamphetamine / Opiates / Heroin / Other Yes (circle which ones)
Are you on probation or parole? Yes / No Do you have a pending cannabis case? Yes / No
Diet: Which do you eat on a daily basis? (circle all that apply)
Meat / Dairy / Processed foods / Fast food / Soda / Vegetables / Fruits / Sweets / White flour
How much coffee/or caffeine drinks do you drink in a day? ___________
How much water do you drink in a day? ___________
Exercise: What do you do for exercise? (circle all that apply)
Walk / Run / Bike / Sports / Dance / Swim / Martial arts / Other_____________Times/week? _____
Cannabis Use Pattern:
Are you new to cannabis use? Yes / No How long have you been using cannabis? _______
Have you ever been issued a cannabis recommendation? Yes / No
Preferred method of medicating: Circle all that apply
Pipe Bong Joint Blunt Vaporizer Concentrate (oil, keif) Edibles Tincture Topical Other
If you ingest, describe in what form _________________
I use cannabis for my medical problem:
__every day or almost every day __more than once a week __ more than once a month.
On the days I use cannabis, I use it __1-2 times __ 2-3 times __more than 3 times
How much do you use per day/week/month? (i.e. #g/day, #oz/month) _______________
My medicine comes from __grow my own __a dispensary __a delivery service __other source
How does cannabis compare with your usual prescribed medicines in relieving your symptoms?
_____________________________________________________________________________
Do you take breaks from using cannabis? If so, for how long? _______ How often? ________
Reason for cannabis abstinence – check all that apply
___tolerance break ___financial–can’t afford it ___access/can’t find preferred form of medicine
___health condition has improved ___other_____________________
All of the above is true to the best of my knowledge________________________________________
(patient signature)