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Exhibit C
Medical Cannabis User Initial Questionnaire
(c)1996 Tod Mikuriya Draft 9, 9-12
Today's Date _____________
Identifying Data
Last name __________________________, First name _____________________
Middle Initial __
Address ________________________ City _______________________
State ____ Zip _________
Res Ph ______-_____-_______ Work Ph _____-_____-______ ext ____
Fax _____-_____-____
Birthdate (MMDDYY) ________ SS# ___-__-____
Sex M _ F _ Ethnic Wh _ B _ Hisp _ Or _ NatAm _ Other _____
Education ___________ Occupation(s) ______________ Unemployed
_ Disabled _
Marital Status: Single _ Mar _ Sep _ Div _ W
_
Living situation: Alone _ Couple _ Group _ Apartment_
House _ Institution _ Homeless _
Health Insurance: None _ Medicaid _ Medicare
_ Workers Compensation _ Other health plan _ (specify) _____________________
ID Number ________________ Group Number __________
Address _______________ City _____________ State ___ Zip _____
Phone ___-___-____x _____
Referred by: Self _ Name __________________________
Institution ____________________
Address _________________________ City _____________ State __
Zip _____
Phone ___-___-____x ______ Fax ___-___-____ Pager ___-___-____
Chief Complaint(s) circle and rank in importance:
example: AIDS related illness 1 anorexia 2
Alcoholism
Alcohol Abuse
Sedative/Opiate Habit
Cocaine or Speed Habit
Nicotine Habit
AIDS related illness
Cancer & cancer Rx
Anorexia
Nausea
Vomiting
Diarrhea
Irritable bowel
Colitis
Cron's disease
Gastritis
Pancreatitis
Hepatitis
Peptic Ulcer
Antibiotic
Asthma
Sinusitis |
Cough
Anxiety
Panic attacks
Insomnia
Mania
Depression
Lethargy
Weakness
Chronic Fatigue Syndrome
Epilepsy
Delirium Tremens
Dementia
Multiple Sclerosis
Huntington's Chorea
Cerebral Palsy
Brain Trauma
Spinal Cord Injury
Muscle spasm
Parkinson's disease
Tremor
Periphal neuropathy |
Tic doloroux
Tourette's syndrome
Glaucoma
Menstrual cramps
Labor pains
Migraine
Meniereís Disease
Hypertension
Itching
Hiccough
Arthritis
Carpal Tunnel Syndrome
Lupus, scleroderma Amyloidosis
Conjunctivitis
Other Pain (specify source)_____
External Use ____
Drug Side Effect control (specify)____
Decrease Use of Other Drugs (specify) _________
Substitute for Other Drugs (specify) ___________
Other ______ |
Chief Complaint ______________________ ICD9-CM
Diagnoses __________ __________ __________
History of Present Illness: (date of onset,
course) _____________________________________________
Past Medical History: (Allergies & adverse drug
reactions): ______________________________________
Family Medical History: ___________________________________________________________________
Social History: _____________________ Drug law
arrests/convictions: None_ Yes (specify) _________
Cannabis type preferred: Sinsemilla _ Mexican
_ Hashish _ No preference _ Other __________________
Age or date Use Begun: ________ Marinol Æ(dronabinol)
2.5 mg _ 5 mg _ 10 mg _ result (+) _ (0) _ (-) _
Route: Oral _ Inhaled: Joint _ Pipe _ Water
Pipe _ Vaporizer _ Other (specify): __________________
Frequency: Monthly _ Weekly _ Semiweekly _ Daily
_ Twice a day _ 3 x a day _ 4 x a day _ more _
Other drugs using - Rx and Over the Counter
_____________________________________________
Has your physician discussed your use of cannabis with you? Yes
_ No _ Discussed any non prescribed psychoactive drugs?
(including alcohol and tobacco) Yes _ No _ Remarks ____________
Completed by: ________________________
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