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 *FirstLastPlease select which of our locations your appointment is at *Click here to select an optionBoca RatonBoynton BeachPlease choose the correct location so the right doctor recieves your informationNext Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *Click here to select an optionMaleFemaleTransgenderPrefer not to sayNext Please upload Drivers License * Click or drag a file to this area to upload. SSN *Social Security Number is required to obtain a Medical Marijuana card in FL.Next Phone *Email *Next Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict 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 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict 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 Please select the medical marijuana product(s) you are interested inFlower, Joints (Smokable)Creams (Topical)Vapes, Concentrates (Inhalation)Tinctures (Sublingual)Food (Edibles)Pills (Oral)SuppositoryIf you are unsure, please leave blankNext 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 AgreePatient/Carer/Guardian Signature * Clear Signature Please 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
