INTAKE FORM First Name* Middle Name Last Name* Date of Birth: Cell Phone* Email* Biological Gender: MF Indication for MMJ card” (pain, PTSD, cancer, etc) How did you hear about us? Do you have any drug allergies? YesNo If Yes, list All Drug ALLERGIES (Including Latex) Are you currently taking any medications? YesNo If Yes, please list medications and dosages Did you have any surgeries? YesNo If Yes, list surgeries and approximate dates PAIN DESCRIPTION (if any) Severity (Scale 1 - 10) Describe your pain Location Duration Frequency Limits Activities / Responsibilities? Explain: MEDICAL HISTORY Personal History of Yes No Explain ALS Yes No Autism Yes No Cancer Yes No Crohn’s Disease Yes No Depression / Anxiety Yes No Diabetes Yes No DVT/PE Yes No Glaucoma Yes No Heart Disease Yes No High Blood Pressure Yes No High Cholesterol Yes No HIV / AIDS Yes No Kidney Disease Yes No Liver Disease Yes No Multiple Sclerosis Yes No Muscle Spams Yes No Parkinsons/Huntingtons Yes No PTSD Yes No Respiratory / COPD Yes No Seizures Yes No Sickle Cell Anemia Yes No Stroke Yes No Thyroid Disease Yes No Ulcerative Colitis Yes No Other Yes No FAMILY HISTORY What medical problems run in your family? Which family members? MotherFatherSiblingChild SOCIAL HISTORY Tobacco: CurrentPriorNever Alcohol: CurrentOccasionallyNever Marijuana: NeverCurrentPrior Other Drug Use: YesNo REVIEW OF SYSTEMS Please check “Yes” or “No” as they relate to your health Constitutional: Unplanned Weightoss Yes No Fever Yes No Chills Yes No Eyes: Glasses / Contacts Yes No Double Vision Yes No Cataracts Yes No Ear, Nose, Throat: Difficulty Hearing Yes No Sinus Trouble Yes No Nasal Stuffiness Yes No Cardiovascular: Chest Pain Yes No Murmur Yes No Fainting Spells Yes No Diffifulty Lying Flat Yes No Palpitations / Heart Racing Yes No Respiratory: Cough Yes No Wheezing Yes No Shortness of Breath Yes No Gastrointestinal: Heartburn/Reflux Yes No Abdominal Pain Yes No Constipation Yes No Nausea Yes No Genitourinary: Burning/Frequency Yes No Blood in urine Yes No Hematology / Lymph: Easy Bruising Yes No Enlarged Glandss Yes No Musculoskeletal: Joint Pain / Swelling Yes No Muscle Pain Yes No Muscle Spasms Yes No Skin: Rash / Sores / Itching Yes No Lesions Yes No Tears Easily Yes No Neurological: Numbness Yes No Weakness Yes No Headaches Yes No Endocrine: Loss of Hair Yes No Heat / Cold Intolerance Yes No Allergic / Immunologic Yes No Hives / Eczema Yes No Psychiatric: Anxiety / Depression Yes No Difficulty Sleeping Yes No Mood Swings Yes No Anxiety Questions Over the last 2 weeks, how often have you been bothered by the following problems? Not at all Several days More than half the days Nearly every day 1. Feeling nervous, anxious or on edge 00 11 22 33 2. Not being able to stop or control worrying 00 11 22 33 3. Worrying too much about different things 00 11 22 33 4. Trouble relaxing 00 11 22 33 5. Being so restless that it is hard to sit still 00 11 22 33 6. Becoming easily annoyed or irritable 00 11 22 33 7. Feeling afraid as if something awful might happen 00 11 22 33 TELEMEDICINE CONSENT FORM I certify that the above information is correct and true to the best of my knowledge. I understand that it is my responsibility to inform this office of any changes with regards to the above information. Telemedicine provides access for therapeutic services using interactive video conferencing tools, such as Skype, in which the doctor and the patient are not at the same location. Telemedicine will allow the patient to receive treatment without the need to visit the office and travel long distance. Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of video); delays in any evaluations and treatment due to deficiencies or failures of the equipment; security protocols can fail, causing a breach of privacy; and a lack of access to all the information available in a face to face visit may result in errors in judgment. Alternative to telemedicine include traditional face to face sessions. I understand that using marijuana may cause short-term side effects like elevated mood, increased appetite, red eyes, dry mouth, and paranoia. More serious problems like pneumothorax are rare but have been documented. There may be a decreased ability to operate machinery and drive a vehicle. For this reason, it is advised not to drive or use heavy machinery while under the influence of marijuana. These short-term side-effects decrease with use and familiarity to its effects. Your Rights: 1) I understand that the laws that protect the privacy and confidentiality of medical information also apply to telemedicine. 2) I understand that Skype is known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data but, like email, may not be HIPAA compliant. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. 3) I have the right to withdraw my consent to the use of telemedicine during the course of my care at any time. 4) I understand that Nature’s Way Medicine has the right to withhold or withdraw consent for the use of telemedicine during the course of my care at any time. 5) I understand that all rules and regulations which apply to the practice in the Commonwealth of Pennsylvania also apply to telemedicine. Your Responsibilities: 1) I will not record any telemedicine sessions, and I understand that Nature’s Way Medicine will not record telemedicine sessions. 2) I will inform my doctor that my environment is secure and confidential. Likewise, my doctor will inform me that the environment in their office is secure and confidential before the session begins. 3) I understand that I MUST be a resident of Pennsylvania to be eligible for telemedicine services from Nature’s Way Medicine. 4) I understand that my Intake will not be done by telemedicine except in special circumstances under which I will be required to verify my identity to Nature’s Way Medicine staff’s satisfaction before the evaluation. Your signature below indicates that you have read and understand the information provided above regarding teletherapy, and that you authorize Nature’s Way Medicine and doctors to use telemedicine in the course of diagnosis and treatment. Signature: Date:
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