Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 28Patient Name *FirstLastWhich of our locations was your last appointment at? *Please select one of our office locations you visitedBoca RatonBoynton BeachNext Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *Click here to select an optionMaleFemaleTransgenderPrefer not to sayNext Please Upload your Florida Marijuana Card * Click or drag a file to this area to upload. If you do not have access to your marijuana card upload drivers licenseNext Phone *Email *Next Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePlease enter your full residential address.Next Please select which option(s) best describe why your seeking medical marijuana today. *ALSAnxiety-InsomniaArthritisCancerCrohn'sDegenerative DiscDementiaDepressionDiverticulitisEndometriosisEpilepsyFibromyalgiaGlaucomaHIVHepatitisIBSLyme DiseaseMSMigraineNeuropathyPTSDParkinson'sSpinal StenosisTremorsUlcerative ColitisNext Current Primary Care Physician Leave blank if you do not currently have another doctorDoctor NameFirstLastDoctor PhoneDoctor EmailNext Current Primary Care Physician's Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLeave blank if you do not currently have another doctorNext MEDICAL HISTORYAre you curently receiving medical treatment? *Click here to select an optionNoYesIf yes, please provide detailsLeave blank if this does not apply to youNext Have you ever suffered a serious illness or injury? *Click here to select an optionNoYesIf yes, please provide detailsLeave blank if this does not apply to youNext Are you currently taking any medication? *Click here to select an optionNoYesIf yes, please provide detailsLeave blank if this does not apply to youNext Are you allergic to any medication? *Click here to select an optionNoYesIf yes, please provide detailsLeave blank if this does not apply to youNext Any other disabilities or conditions not mentioned? *Click here to select an optionNoYesIf yes, please provide detailsLeave blank if this does not apply to youNext Please check any diagnoses/symptoms you are currently having:General Diagnoses/Symptoms *NoneBleeding DisorderCancerChills/SweatsDepression/NervousnessDiabetesDizziness/FaintingElevated ThyroidFeverForgetfulnessHeadacheKidney DiseaseLiver DiseaseLoss of SleepMigrainesNumbnessStrokeVaricose VeinsWeight LossNext Neurological Diagnoses/Symptoms *NoneAlzheimer’sAmyotrophic lateral sclerosis(ALS)EpilepsyMultiple sclerosisParkinson’s diseaseStrokeNext Psychiatric Diagnoses/Symptoms *NoneAnxietyBipolarDepressionInsomniaPTSDSchizophreniaNext Genito-Urinary Diagnoses/Symptoms *NoneBlood in UrineFrequent UrinationHerpesLack of Bladder ControlPainful UrinationNext Muscle, Joint, and Bone Diagnoses/Symptoms *NoneArthritisBack PainFeet NumbnessFeet PainFeet WeaknessHand NumbnessHand PainHand WeaknessHip PainLeg PainLeg PainMultiple SclerosisNeck PainShoulder PainNext Gastrointestinal Diagnoses/Symptoms *NoneBloating/GasBowel ChangesConstipationDiarrheaHemorrhoidsHepatitisIndigestionNauseaPoor AppetiteRectal BleedingStomach PainThirstUlcersVomitingVomiting BloodNext Cardiovascular Diagnoses/Symptoms *NoneAtrial FibrillationBlood Pressure (High)Blood Pressure (Low)Chest PainHeart DiseaseHigh CholesterolIrregular/Rapid Heart BeatPacemakerPoor CirculationSwelling in AnklesNext ENT and Eyes Diagnoses/Symptoms *NoneBleeding GumsBlurred VisionCrossed EyesDifficulty SwallowingDouble VisionEarache/DischargeGlaucomaHearing LossHoarsenessNosebleedsRinging in EarsSinus ProblemsVision Flashes/HalosNext Pulmonary Diagnoses/Symptoms *NoneAsthmaCOPDEmphysemaLung NodulesPersistent CoughPulmonary EmbolismShortness of BreathSleep ApneaTuberculosisNext Skin Diagnoses/Symptoms *NoneBruise EasilyChanges in MolesHives RashSores that won't healNext Other Diagnoses/Symptoms (Had in the past)NoneAIDSChicken POXHIVMeaslesMumpsPolioRheumatic FeverScarlet FeverNext Check illnesses, diagnose, and symptoms that have occurred in your Blood Relatives *NoneBleeding DisordersCancerDiabetesHeart DiseaseHigh/Low Blood PressureNervous IllnessProstate ProblemsStrokeNext Current Prescription, Dosages, and Routes *Leave the same, no further action neededRequest Doctor to contact me to make changesNext I certify that the above information is correct to the best of my knowledge. I will not hold the doctor, office, or staff responsible for any errors or omissions that I may have made in the completion of this form. I also understand that my prescription may be adjusted to reflect any changes by the state on maximum dosages allowed. By checking this box, I acknowledge and agree that Oasis Marijuana Doctors and its doctors and staff have complied with Florida telehealth laws as defined in Florida Statute 456.47. I understand that telehealth includes the use of synchronous or asynchronous telecommunications technology for health care services. I acknowledge that telehealth providers may conduct patient evaluations and provide health care services without conducting a physical examination or researching a patient's medical history. I am aware that telehealth providers may only prescribe certain controlled substances in specific situations, as outlined in the statute. I understand that telehealth services may be provided when the telehealth provider and I are in separate locations. I also understand that telehealth services will be documented in my medical record in accordance with the same standards as in-person services. By checking this box, I confirm my understanding and agreement to these terms. *I AgreePatient/Carer/Guardian Signature *Clear SignaturePlease use your finger to sign aboveNext How easy was this form to complete? *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Continue
