Medwell Health and Wellness Centers. Don T Live with PAIN Live WELL Medwell

MedWell Health and Wellness Centers. Don’t live with PAIN Live WELL… MedWell

Welcome to MedWell

Patient Information Date: ______

Name: ______

Date of Birth: ______/______/______

Address: ______

______

City: ______State: ______Zip Code: ______

Cell Phone: (______) ______-______

Home Phone: (______) ______-______

Email:______

Gender: o Male o Female

Last four Social Security Number: -______

How did you hear about MedWell: o Facebook o Commercial o Penny Saver Ad

o Friend’s name ______

o Newspaper ______

o Referred by ______oOther______

Your Primary care physician information

Name: ______

Address: ______

City: ______State: ____________

Have you had a medical marijuana recommendation from a doctor before? o Yes o No

If yes, please provide name of physician and/or practice ______

Review of Symptoms:

General Gastrointestinal Muscle/Joint/Bone/Pain

o Anxiety o Abdominal pain or cramps o Neck o Legs

o Chronic Pain o Bowel changes o Shoulder o Knees

o Dizziness o Nausea o Back o Ankles

o Headache o Poor Appetite o Arms o Feet

o Loss of Sleep o Vomiting o Hands o Arthritis

o Loss of weight o Hips o Muscle Cramps

Psychiatric Cardiovascular Neurological

o Anxiety o Cardiac Palpitations o Fainting

o Depression o High Blood Pressure o Headache

o Disturbing feelings o Irregular heartbeat o Numbness

o Panic Attack o Rapid Heartbeat o Seizures

o Restlessness o Neuropathy

Current Conditions

o Aids o Alcoholism Chemical Dependency o Anorexia o Anxiety o Arthritis

o Cancer o Chemical Dependency o Chronic Pain o HIV Positive

o Depression o Epilepsy o Fibromyalgia o Glaucoma

o Insomnia o Migraine Headaches

Current Diagnoses: ______

Medications

Over the counter______

Prescribed______

Chief Complaint

Please describe the medical condition(s) or complaints that you are seeking a recommendation for medical marijuana. (How long have you had symptoms/diagnosis?)

______

Additional Information

Please provide any other information you believe is relevant to the doctor’s evaluation:

______

I understand that the physician may be contacted to verify and/or authorize my status as their patient as well as any prescription and/or recommendation that may or may not be issued by them. By signing below I hereby authorize the physician and/or MEDWELL to make such verifications or authorization. My signature below shall serve as a release for this purpose only and shall not serve as a waiver of my other patient and physician privacy rights as detailed under Massachusetts State Laws and Federal HIPAA regulations.

Patient Signature______Date___/___/______

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