PERSONAL INFORMATION. Last Name First Middle Initial. Street Address City State CO Zip. Mailing Address City State CO Zip. Home Phone Cel Phone Office

PERSONAL INFORMATION Date:______________________ Last Name_________________First ____________________Middle Initial_____ Date of Birth________________...
Author: Milo Wells
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PERSONAL INFORMATION Date:______________________ Last Name_________________First ____________________Middle Initial_____ Date of Birth_________________Age______Sex__M / F Street Address ____________________City ________________State CO Zip________ Mailing Address___________________City ________________State CO Zip________ Home Phone _________________Cel Phone_______________Office_____________ Colorado Drivers License #________________________Expiration Date____________ Social Security #________________________________ Email_________________________________________

Primary Care Physician ____________________________________________ Mailing Address:________________________City________________State_____ Zip___________ Phone Number______________________Fax #___________________________

PATIENT TO FILL OUT PAGES 1,2,&3

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History Last Name___________________First Name___________MI___DOB_____________ Date______________________ Chief Complaint________________________________________ History of the present illness: When did it start_____________________ Allergies to Medication ________________________________________________________________________ _______________________________________________________________ Medications:_____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Surgery_________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Social History:_______Alcohol,_______Tobaco______ Do you currently use Marijuana_______________ Does Marijuana help you ailment______________ Medical History:_____ HIV, _____AIDs,_____ Cancer,_____ Diabetes,__ Hypertension, _____Heart Disease,_____ Pulmonary Disease, _____Kidney Disease, _____Hepatitis, Review of Systems: General: _____Fever, _____Chills,_____ Sweats, _____Weight Loss,_____ Weight Gain 1. Head: ____Trauma 2. Eyes: _____Glaucoma _____Pain, _____Blindness, _____Visual field Loss, Double Vision, Blurred vision, Glasses, Cataract, Trauma, Conjunctivitis, Sty, _____Surgury. _____Infection, _____Cancer 3. Ears: _____Pain, _____Deafness,_____ Ringing,_____ Dizziness, _____Infection 4. Nose: _____Pain, _____Cancer, Bleeding,_____ Loss of Smell, _____Difficulty Breathing, _____Sinus Infection, _____Surgery 5. Throat: _____Pain, _____Cancer _____,Difficulty Swallowing,_____ Hoarsness, _____Decreased taste, ______Difficulty Speaking, _____Tonsillitis, _____Herpes Simplex 6. Neck: _____Pain, _____Cancer,Trauma, _____Limitation of motion, _____Swelling,_____ Surgery,_____ Thyroid Disorder,_____ Parathyroid Disorder

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7. Chest: _____Pain,_____ Cancer,_____ Cough, _____Difficulty Breathing, ______Asthma,_____ Pneumonia,_____ Tuberculosis,_____ Coughing up Blood, _____Coughing up Green Sputum, _____Rib Fracture, _____Surgery, _____Thorasic spine Pain 8. Cardiovascular: ____Chest Pain, _____Angina,_____ Heart Attack, 9. _____ Irregular Rhythum,_____ Heart Failure,_____ Pacemaker, _____Heart Surgrey,_____ Angioplasty,_____ Bypass surgery,_____ Valve Replacement. _____Infection 10. Gastrointestinal: _____Nausea,_____ Vomiting,_____ Pain, Diarrhea, _____Black Stool,_____ Bloody Stool,_____ Clay Colored Stool,____ Constipation, _____Liver Disease,_____ Hepatitis,_____ Cirrosis, _____Cancer, _____Esophageal Reflux,_____ Gastric Ulcer Disease, _____Gall Bladder Disease,_____ Chrones Disease, _____Colon-Rectal Cancer,_____ Hemorroids, _____Abdominal Infection 11. Genetal Urinary: _____Pain,_____ Kidney Disease,_____ Kidney Stones, ____Burning on Urination,_____ Urinary Frequency,_____ Bloody Urine, _____Incontinance,_____ Difficulty Urinating (Starting and Stopping),_____ Dialysis, _____Impotance,_____ Infection,_____ Surgery,___ Herpes Simplex 12. GYN: ____Pain._____ Painful Menstration _____Pain with Ovulation, _____Pain with Intercoarse, _____Endometriosis, _____Ovarian Cysts, _____Cancer, _____Uterine Infection,_____ Abnormal Pap Smear,____ Bartholin Abcess or cyst,_____ Herpes Sinplex,_____ Gonorrhea. 13. MusculoSkeletal: _____Pain,_____ Muscle Spasm,_____ Broken Bones._____ Joint Pain, _____Loss of Muscle Mass,_____ Weakness,_____ Joint Swelling, _____Joint limitation of Motion,_____ Neck Pain, _____ Low Back Pain,_____ Hip Pain,_____ Knee Pain, _____Sholder Pain,_____ Surgery. 14. Neurologic: _____Head Trauma,_____ Concussion, _____Seizures,___ Epilepsy, _____Brain tumor, _____Fractured Skull, _____Herniated Disk in Back or Neck, _____Lumbsacral Strain with Spasm, _____)Multiple Sclerosis and Spasm, _____Weakness, _____Numbness, Dizziness,_____ Difficulty Standing, _____Insomnia, _____Dementia, _____Slurred Speech, ____Difficulty Walking, _____Difficulty with Balance. I hereby certify that the above Medical History is accurate the best of my ability. Patient Signature:_______________________________Date__________________

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Physical Examinaton Last Name_______________________First Name______________MI___DOB_______ Vital Signs : Temperature______Pulse______BP______R______ Height:_____ Weight:______ Head: _____Normal, _____Trauma,_____ Scars, Eyes: _____Normal, _____Eom’s intact, _____Normal Pupils,_____ Fundesscopic Ears: _____Normal,_____Hearling,_____External Ear, _____Canal,_____ Cerumen, _____Tympanic Membrane, Nose: _____Normal,_____ Septum,_____ Sinus Tenderness Mouth: _____Normal,_____ Teeth,_____ Tongue, _____Phonation, _____Pharynx, Neck:_____ Normal,_____ Pain,_____ Range of Motion,_____Carotids,_____ Neck Veins,_____ Thyroid,_____Cervical Nodes,_____ Scars. Chest: _____Normal,_____ Pain,_____ Vertebral Tenderness,_____ Scoliosis,___ Scars, _____Percussion Dullness,_____ Breath Sounds,_____Rales,_____Wheezing, _____Retraction,_____ Deformity,_____Scars. Cardiovascular: ______Normal,_____ Rhythm,_____ PMI, _____Neck Veins,___ Murmur,_____ Carotid Pulse, _____Radial Pulse,_____ Femoral Pulse,____ Dorsalis Pedis Pulse, Gastrointestinal:_____ Normal,_____ Tendeness, _____Bowl Sounds,_____ Masses, _____Liver Enlargement, _____Enlarged Spleen,_____ Hernia,_____ Bruits,_____ Scars, _____CVA Tenderness, Lymph Nodes: _____Normal, _____Cervical Nodes, _____Axillary Nodes, _____ Femoral Nodes, Skin: _____Normal,_____ Rashes,_____ Masses,_____ Actinisc,_____ Moles,

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Musculoskelatal: _____Normal,_____Cervical Spine, _____Thorasic Spine, _____Lumbar Spine,_____ Scars, _____Sholders,_____ Elbows,_____ Wrists, _____ Hands, _____Hips,_____ Knees,_____ Feet,_____ Muscles, Neurologic: _____Normal,_____ Orientation,_____ Motor Function,_____ Sensory Function, _____Deep tendon Reflexes,___Gate, ____Ataxia,__ Rhomberg, ___Babinski, Notes: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Diagnosis: Cancer__________________________________________________________________ Glaucoma_______________________________________________________________ HIV/ AIDS______________________________________________________________ Cachexia ________________________________________________________________ Severe Pain______________________________________________________________ Severe Nausea____________________________________________________________ Seizures (including those associated with epilepsy)_______________________________ Persistant Muscle Spasm (including those associated with Multiple Sclerosis)_________ It is my opinion that the patient might benefit from the use of medical marijuana. This is not a prescription for medical marijuana. The patient understands that medical marijuana can impair judgment and physical capabilities and agrees not to use medical marijuana while caring for others, or operating hazerdous equipment, including automobiles, that would cause harm to ones self or others. The Patient also agrees to return to his or her Primary Care Physician (_____________________________________) for ongoing care of the above conditions. Patient Signature:_______________________________________Date______________ Physician Signature:_____________________________________Date______________

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