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IMPORTANT​: THIS INTAKE FORM IS TO ASSIST THE ATTENDING PHYSICIAN IN EVALUATING PERSONS APPLYING FOR AN OREGON MEDICAL MARIJUANA CARD. THE OMMC CLINIC AND THE ATTENDING PHYSICIAN ARE NOT RECOMMENDING OR PRESCRIBING MARIJUANA, BUT ARE SIMPLY CERTIFYING THAT YOU HAVE AN OMMP QUALIFYING CONDITION THAT MIGHT BENEFIT BY USING MARIJUANA (CANNABIS). THIS IS NOT A GENERAL PHYSICAL OR CHECK-UP. BEFORE COMPLETING THIS INTAKE FORM, READ AND SIGN BELOW INDICATING YOU UNDERSTAND AND AGREE.


WHAT WILL NOT​ HAPPEN IN THIS CONSULTATION:

  • This consultation will ​NOT​ include diagnosis or treatment for any other medical conditions you may currently be experiencing. No blood tests, imaging studies, labs, prescriptions, or medications will be recommended or prescribed.

  • The attending physician is ​NOT​ your Primary Care Physician and completing this consultation will not make the attending physician your Primary Care Physician.

  • If you need advice or treatment for any medical conditions or symptoms, you should contact your Primary Care Physician or any other physician of your choice for evaluation and treatment.


WHAT ​WILL​ HAPPEN IN THIS CONSULTATION:

  • You have scheduled a consultation with an attending physician regarding the medicinal use of marijuana (cannabis) to mitigate certain medical symptoms or disorders.

  • The attending physician will review your medical records, conduct a basic physical examination, discuss follow-up, discuss a treatment plan and document these activities in your medical record.

  • The physician will evaluate your medical history, current medical condition and discuss with you the risks and benefits of the medicinal use of marijuana related to obtaining a registry identification card under the Oregon Medical Marijuana Program (OMMP).

  • The physician will complete the Attending Physician Statement Form required for an OMMP application in the manner in which the physician believes is accurate in his or her sole opinion and in accordance with the OMB, Oregon Health Authority and the OMMP.

  • Meeting with the physician does not guarantee you will receive an OMMP card, as the Oregon Health Authority is the issuing agency. We will, however, provide all the necessary documents necessary to apply for an OMMP card through the State of Oregon.


I HAVE REVIEWED THE ABOVE INFORMATION. I UNDERSTAND THE SCOPE AND LIMITATIONS OF THIS CONSULTATION.



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OMMC Clinic Patient Intake Form

NAME

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How did you hear about our office?








1. Have you been seen at the OMMC Clinic before?

     

2. Have you received an Oregon Medical Marijuana Card before from another office?

     

3. Have you ever obtained a medical marijuana card in another state?

     

4. Within the last 1 - 2 years, have you used marijuana (cannabis) to treat the condition or symptom (ie pain, muscle spasm, nausea) you are using in your OMMP application?

     

5. If you have used marijuana before, have you experienced any adverse effects or side effects from using it?





6. Do you have a history of serious heart disease such as a previous heart attack, serious chest pain coming from the heart, or have you had cardiac bypass surgery?

  

7. Employment

Describe briefly the type of work you to. For example: laborer, desk worker, student, accountant, police officer, etc. If you are retired please put retired and describe the work you retired from. If disabled, indicate how long you've been disabled and what type of work you did last.

Would you describe this work as:

     

     

     

8. Do you use tobacco products?

  

  

  

9. Do you consume alcohol?

  



10. Are you currently taking any prescription medications?

  

11. Are you allergic to any medications?

  

12. What type of treatment have you been given for this condition in the past? If you have not received treatment for this condition please indicate “no treatment” and give the reason why you have not received treatment. Please be specific.

13. Please list any surgeries and approximate date:

14. Please list any other medical conditions, hospitalizations, and/or treatments you have had that are not listed above:

PAST MEDICAL HISTORY

Check below if you have experienced any of the following:


















































FAMILY HISTORY














REVIEW OF SYSTEMS

Please check any areas you are having problems with:















































Female Patients (Male Patients Continue to Next Section "All Patients")

Due to the potential health risks associated with marijuana (cannabis) and childbirth and breast feeding, please answer the following:


1. During your lifetime, how many pregnancies have you had?

2. How many of these pregnancies resulted in the birth of a baby (living or not)?

3. BIRTH CONTROL – Are you currently using some type of birth control that will keep you from getting pregnant while using cannabis?


Examples are birth control pills, condoms, IUDs, hormone shots, tubal ligation your sexual partner has been sterilized, you are not sexually active with a male.

     

4. Are you currently pregnant?

     

5. Are you planning to become pregnant?

     

6. Are you currently breastfeeding?

     


New Patient In-Clinic Tan Questionnaire

1. Please check one or more Qualifying Conditions you are using in your OMMP application:








2. In the space below, briefly describe the diagnosis being used as the Qualifying Condition in your OMMP application and include how and when you developed the problem(s). For example: if you have migraine headaches you might say: "Migraines. Began when I was a teenager". For arthritis you might say: "Arthritis in my knees and hands. Began ten years ago". Suppose you have neck pain following a car accident you might say: "Neck pain since motor vehicle accident in 2011". Please be as brief as possible:

3. Do you still obtain medical help for the condition(s) described above?

     

4. About how long has it been since you’ve seen a healthcare provider for this condition?

5. Check ONE BOX that best describes how often you see a healthcare provider for this condition. Examples of a healthcare provider would include, but are not be limited to: physician, chiropractor, acupuncturist, massage therapist, psychiatrist or other mental health professional, naturopath, etc.







6. Check the ONE BOX that best describes your work activity at the current time:













7. Is this your first medical cannabis card?

     

8. Within the last year have you been user of cannabis (either medically or recreationally)?

     

9. If “Yes” to Question 8 – please check every box how you are using the cannabis:







Blue Questionnaire for OMMC Clinic Renewing Patients

Please answer the following questions:

Q. 1: Do you still have or suffer from the condition(s) you originally used in your OMMP application (ie. severe pain, muscle spasm, severe nausea, etc.)?

     

Q. 2: How long ago did you last see a healthcare provider for this condition?

Q. 3: Check the ONE box that best describes how often you see your healthcare provider for your condition:





Q. 4: If you were not approved by the Oregon Health Authority to renew your OMMP card and thus would not be allowed to continue using medical cannabis, what do you think would happen with the symptom or condition you used (such as pain or muscle spasm) in your OMMP application?



Q. 5: How often do you use your medical cannabis?




Q. 6: How do you normally use your cannabis? Check all that apply:






Q.7: List any complications or problems you have had with the medical cannabis. Please check NONE if you have had no complications:


Q. 8: Check ONE box that best describes your work activity during this past year.











All Patients

I certify that I have read this document and that the answers I have provided are true and complete and that I will only present factual and complete medical history to the attending physician.


I acknowledge that any manipulation, alteration, or falsification of this form, or providing false information to the attending physician could result in the immediate termination of any legal right to my use of medical marijuana. Furthermore, I understand the attending physician’s office will report the false and invalid application to state authorities.



RELEASE OF LIABILITY


Please read each item below and initial in the space provided to indicate that you understand and agree to each item. DO NOT sign this agreement and do not use medical marijuana if you do not understand the information you have received.











I, (Print Name)*, MY HEIRS, ASSIGNS, OR ANYONE ELSE ACTING ON BEHALF, HEREBY RELEASE AND HOLD OMMC CLINIC, ITS PRINCIPALS, AGENTS AND EMPLOYEES, AND THE ATTENDING PHYSICIAN FREE OF AND HARMLESS FROM ANY RESPONSIBILITY AND/OR LEGAL LIABILITY FOR ANY HARM RESULTING TO ME AND/OR OTHER INDIVIDUALS THAT MAY ARISE FROM MY HANDLING OR CONSUMPTION OF MARIJUANA, AND FROM THE USE OF FACILITIES OPERATED BY OMMC CLINIC.



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