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**

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Email *
First name *
Last name *
Phone number *
Mailing Address  *Please provide and do not write same* *
City *
State *
Zip Code *
Does the above address match your ID *If no please provide the address that matches your ID* *
Required
Date of Birth *
Please provide the name your primary care provider. *
What town is your Primary care provider located in?  *
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: *
Cannabis History
Are you currently using cannabis? (If no, please skip to next section). *
What delivery methods do you use? *
Required
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:
GENERAL
HEAD
BREATHING
HEART & CIRCULATION
DIGESTIVE
URINARY
MUSCULOSKELETAL
NEUROLOGICAL
MENTAL HEALTH
OTHER
FOR WOMEN
FOR MEN
Have you been bitten by a black legged (deer) tick? *
If yes, did you get a circular rash in the area of the bite?
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Have you experienced a flu-like illness in the summer or fall from which you never fully recovered? *
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