Follow Up Health History
Welcome back, and thank you for taking a couple minutes to complete our intake and consent forms. We look forward to the opportunity to serve you. The information you submit in this HIPAA-secure form is protected health information and will be used only by this office unless you provide a written release. **Please do not use use your auto-fill function, it creates a problem for some users that prevents advancing and completing the form**
Date of Birth
Please provide the name and town of your primary care provider.
May we send a copy of your visit notes to your primary care provider or other relevant specialists?
What are your health and healing goals? What are your goals for this visit?
Please list your current health concern(s):
Please describe any changes or updates in your health condition(s) and quality of life since your last visit:
Are you currently using cannabis? (If no, please skip to next section).
What delivery methods do you use?
Tincture or oil
Please describe how much cannabis you use (e.g. 20mg CBD 3x/day, or 2 puffs 2x/day, or 1⁄4 oz/week)
How does cannabis help you?
In your experience with cannabis, what has worked well, and what hasn’t worked well?
Have you had any negative effects from cannabis? (Yes / No) If yes, please describe:
Please list all of your current medications, supplements, and herbs (with dosages):
Other Symptoms – please check any that you’ve experienced in the last 2 weeks:
Feel like you’ve aged prematurely
Shortness of breath
HEART & CIRCULATION
Trouble breathing when laying down
Trouble walking upstairs
Legs cramp after walking
Heart races or skips beats
Heartburn or reflux
Blood in vomit or stools
Black or tarry stools
Excess belching or passing gas
Pain or burning with urination
Blood in urine
Painful muscles or tendons
Pains that come and go or move around w/out a clear reason
Trouble with balance
Inability to process numbers
Unprovoked mood swings
Thinking about harming myself / another
Can’t tolerate heat / cold
Change in appetite / thirst
Trouble or pain with sex
Problems with periods
Lumps in breasts
Lumps or pain in testicles
Have you been bitten by a black legged (deer) tick?
If yes, did you get a circular rash in the area of the bite?
Have you experienced a flu-like illness in the summer or fall from which you never fully recovered?
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This form was created inside of Integr8 Health.