Ohio Holistic Healthcare

570 North Leavitt Road

Amherst, OH 44001

(440) 340-1970 (phone)

(440) 370-3026 (fax)

www.ohioholistichealthcare.com

ohhc2018@gmail.com

PATIENT INTAKE FORM

*Complete & Bring to Appointment

TODAY’S DATE:_____________________________        REFERRED BY:___________________________________

PATIENT NAME:______________________________________________________________________________

D.O.B._____________________________________LAST FOUR OF SS#:***-**-___________________________

SEX:           MALE          FEMALE                             MARITAL STATUS:  SINGLE  MARRIED  DIVORCED WIDOW

ADDRESS:___________________________________________________________________________________

CITY:________________________STATE:______________________ZIP:________________________________

HOME PHONE:___________________________CELL PHONE:_________________________________________

WORK PHONE:___________________________EMAIL:_______________________________________________

(PLEASE CIRCLE PREFERRED CONTACT NUMBER AND  AM OR PM)

PLACE OF EMPLOYMENT:______________________________________________________________________

JOB TITLE:___________________________________________________________________________________

HIGHEST DEGREE ATTAINED:___________________________________________________________________

MILITARY EXPERIENCE:  Y     N        COMBAT:  Y    N    BRANCH:_________________RANK:________________

ARE YOU CURRENTLY ON PROBATION OR PAROLE?      Y      N      EXPLAIN:____________________________

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PRIMARY CARE PRACTITIONER:_________________________________________________________________

ADDRESS:____________________________________________________________________________________

CITY:______________________________STATE:_______________________ZIP:__________________________

PHONE:______________________________________FAX:____________________________________________

THERAPIST CONTACT INFORMATION:____________________________________________________________

ADDRESS:____________________________________________________________________________________

CITY:______________________________STATE:_______________________ZIP:__________________________

PHONE:______________________________________FAX:____________________________________________

HAVE YOU DISCUSSED MEDICAL MARIJUANA WITH YOUR PCP OR THERAPIST?                  YES                 NO

HOW DID THEY RESPOND?_____________________________________________________________________

PLEASE LIST ANY ALLERGIES:__________________________________________________________________

_____________________________________________________________________________________________

PLEASE LIST CURRENT MEDICATIONS WITH DOSING:____________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLEASE LIST PAST SURGERIES AND DATES: (APPROXIMATE) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PAST MEDICAL HISTORY:(PLEASE CHECK IF YOU HAVE BEEN DIAGNOSED WITH ANY OF THE BELOW)

FAMILY MEDICAL HISTORY:

PAIN HISTORY

Mankoski Pain Scale:  my pain ...

Nature of pain is:  (circle all that apply)

       acute        sharp                       radiating        burning                

       chronic (6 months or more)        associated with numbness        

Location of pain:_______________________________________________________________

Underlying diagnosis:__________________________________________________________

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PLEASE LIST THE CURRENT CONDITION(S) YOU HOPE TO MEDICATE WITH CANNABIS: __________________________________________________________________________________________________________________________________________________________________________________________

CANNABIS USE HISTORY:

       AGE OF FIRST USE:____________________

       PREFERRED CANNABIS TYPE:___________________________________________________________

       PREFERRED INTAKE METHOD:___________________________________________________________

       FREQUENCY OF CANNABIS USE:_________________________________________________________

       AMOUNT USED (GRAMS/WEEK):__________________________________________________________

       HAVE YOU EVER USED MARINOL (THC IN PILL FORM)?            YES              NO          

                WHY AND RESULTS?_________________________________________________________

       HOW & WHEN DID YOU DISCOVER THAT CANNABIS HELPED YOUR SYMPTOMS?   __________________________________________________________________________________________

SOCIAL HABITS:  (PLEASE CHECK ALL THAT APPLY)

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***OFFICE POLICIES AGREEMENT***

By signing below, you acknowledge that you have read, understand, and agree to the following policies:

  1.  An annual appointment is required to renew medical marijuana recommendation letters by state law.
  2.  Cost for office appointment for initial evaluation and assessment for medical marijuana is $250.
  3.  24 hour notice is required for cancellations.  There is a $50 fee for no-shows.
  4.  A written recommendation for medical marijuana cannot exceed 90 days.
  5. Ohio mandates a OARRS query be done on all patients.
  6. Parental consent must be obtained for all recommendations to minors.
  7. Prescription refill requests must be called at least 72 hours in advance and may require an appointment.        

_________________________________________________             __________________________________

Patient Signature                                                            Date