Florida Medical Marijuana Intake Form

Please fill out the following medical assessment . The information you provide will assist the medical provider in determining the most appropriate course of treatment for you.

Step 1 of 9

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Patient Identification

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Florida Residency Address(Required)

Street Address Address Line 2 City State ZIP Code

Chief Reason / Symptom(s) you hope medical marijuana will address(Required)

Past Cannabis / Substance Use (frequency, dose, adverse effects) (Required)

Current Medications

Blood Thinners (Anticoagulants / Antiplatelets)(Required)

Yes

Diabetes Medications(Required)

Yes

Blood Thinners (Anticogulants / Antiplatelets) info, if yes(Required)

Diabetes Medication info, if yes(Required)

Psychiatric Medications(Required)

Yes

Pain Medications (Opioids, NSAIDs, Gabapentin, etc.)(Required)

Yes

Psychiatric Medications info, if yes(Required)

Pain Medications (Opioids, NSAIDs, Gabapentin, etc.) info, if yes(Required)

Seizure Medications (Anticonvulsants)(Required)

Yes

Respiratory Medications (Inhalers for Asthma/COPD)(Required)

Yes

Seizure Medications (Anticonvulsants) info, if yes(Required)

Respiratory Medications (Inhalers for Asthma/COPD) info, if yes(Required)

Steroids / Immunosuppressants(Required)

Yes

Blood Pressure / Cholesterol Medications(Required)

Yes

Steroids / Immunosuppressants(Required)

Blood Pressure / Cholesterol Medications(Required)

Red-Flag Symptom Questions

Suicidality / Self-Harm Risk • In the past week, how often have you had thoughts of hurting yourself or that life isn’t worth living? (Required)

0 = Not at all

1 = Rarely (once or twice)

2 = Frequently (several days)

3 = Almost every day / persistent

Hallucinations / Psychosis • In the past week, have you noticed hearing voices, seeing things, or sensing things that others could not?(Required)

0 = Not at all

1 = Slightly (uncertain or fleeting)

2 = Moderately (clear but not constant)

3 = Severe (persistent, distressing, or commanding)

Mood Instability / Rapid Swings • How often in the past week have your moods shifted quickly and intensely (for example, from feeling very high/energized to very low/irritable)?(Required)

0 = Not at all

1 = Rarely (once or twice)

2 = Frequently (several days)

3 = Almost every day / persistent

Substance Use Screening (Cannabis or Other Substances)

Frequency of Past Use : How often have you used cannabis (or other substances) in the past?(Required)

0 = Never

1 = Occasionally (less than once a month)

2 = Regularly (monthly to weekly)

3 = Frequently (daily or almost daily)

Typical Dose / Amount : When you used, how much did you typically consume at one time?(Required)

0 = Never

1 = Small amounts (e.g., 1–2 puffs, minimal use)

2 = Moderate (e.g., several puffs, 1 edible, moderate dose)

3 = Heavy (e.g., multiple joints, high-dose edibles, concentrated

Typical Dose / AAdverse Effects Experienced : Did you experience any negative effects from cannabis or other substances (e.g., anxiety, paranoia, memory issues, physical side effects)?(Required)

0 = None

1 = Mild, short-lived effects

2 = Moderate, caused some distress or impairment

3 = Severe, caused significant problems (e.g., ER visits, inability to function, accidents)mount : When you used, how much did you typically consume at one time?

Past Medical History (Qualifying Conditions)

Cancer(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Epilepsy / Seizure Disorder(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Glaucoma(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

HIV / AIDS(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Crohn’s disease / IBD(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Parkinson’s disease(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Multiple sclerosis(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Amyotrophic lateral sclerosis (ALS)(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

PTSD(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Chronic nonmalignant pain (>6 months)(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Terminal illness (life expectancy <12 months)(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Other qualifying condition

Current Symptom Burden (Last 2 Weeks)

Pain severity(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Muscle spasms(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Nausea / vomiting(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Anxiety / PTSD symptoms(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Insomnia / sleep disturbance(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Appetite loss / unintended weight loss(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Seizure frequency(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Daily function impairment(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Social & Lifestyle History

Tobacco use (current)(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Alcohol use (typical week)(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Illicit drug use (past 12 months)(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Cannabis use history (lifetime frequency)(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Employment impact of condition(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Driving/heavy machinery risk if impaired(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Sexual Orientation & Practices (Risk Profile)

Sexual orientation & practices(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Psychiatric & Risk Factors

History of substance use disorder(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Depression severity(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Anxiety severity(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Psychosis or schizophrenia(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Cognitive impairment / memory issues(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Pregnant or breastfeeding(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Consent & Legal Understanding

Understands federal illegality vs. Florida legality(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Consents to be entered into Registry(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Willing to attend follow-up visits(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Understands restrictions on public use, firearms, driving(Required)

0 - None

1 - Low

2 - Moderate

3 - Strong

Compliance Additions (Florida Statute)

Prior conventional treatments attempted and failed ?(Required)

Yes

Describe current medications, supplements, therapies

Consent

I have been counseled on risks of marijuana use during pregnancy/breastfeeding.

Consent

I understand I may not drive or operate heavy machinery under the influence of marijuana.

Consent

I must apply for and maintain a valid Medical Marijuana Use Registry ID card. Submit Form