Patient History Questionnaire


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,


❑ 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


❑ 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)