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Cannabis Intake Form

Please fill out the following form completely.

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1. For which medical condition do you take medical cannabis?
4. Do you take any of the following prescribed medications?
5. Have you been diagnosed with mental illness?
6. Do you have a family history of schizophrenia?
7. Do you suffer from heart disease?
8. Do you suffer from irregular heart rate?
9. Is this the first time you are requesting a recommendation for medical marijuana/cannabis use?


I am aware that the use of cannabis may IMPAIR my ability to DRIVE and I can get a DUI. In addition, other medications or ALCOHOL may cause more impairment. I am also aware that cannabis smoke contains tars which may be harmful. I understand that SIDE EFFECTS may occur which include but are not limited to: low blood pressure, dizziness, anxiety, heart palpitations, impairment of short term memory, paranoia and hallucinations. I understand that I may become DEPENDENT on cannabis use and may experience WITHDRAWAL symptoms which may include irritability, sadness, and insomnia.


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