420 Cannabis Clinic: Medical History Form 420 Cannabis Clinic: Medical History Form Name * First Name Last Name Date of Birth * MM DD YYYY Address * Please fill out the information below to the best of your knowledge. If the question does not apply to you, please leave blank. MEDICAL HISTORY Past medical history (Such as diabetes, high blood pressure, back pain, ect...) * Current Prescription and Over the Counter Medications * Medication Allergies * Tobacco use and frequency: * Alcohol use and frequency: * Illicit drug use and frequency: * TREATMENT EFFECTIVENESS FOR QUALIFYING CONDITION Please answer the following questions on how effective your current treatment plan is for your medical condition. Current treatments (medications, therapy, etc…) for your medical condition * How effective are these in your treatment? * NOT AT ALL MILD MODERATE SIGNIFICANT For individuals renewing their medical cannabis card: How effective is medical cannabis in your treatment NOT AT ALL MILD MODERATE SIGNIFICANT Are you having any side effects from medical cannabis? Date * MM DD YYYY I certify the above information is true and correct : Thank you!