Patient Questionnaire

Filling out this form does not guarantee an approval or recommendation for the use of medicinal cannabis.

STEP 1 - PATIENT INFORMATION
STEP 2 - PATIENT MEDICAL INFORMATION
Which condition are you requesting medical marijuana treatment for?
STEP 3 - SAVE YOUR INITIALS
Use your mouse or finger to sign below. Click "Add Initials" after signing.
STEP 4 - PLEASE INITIAL TO CONFIRM YOU ACKNOWLEDGE THE FOLLOWING
The efficiency and potency of Medical Marijuana may vary widely depending on the strain and ingestion method.
There is limited information on the side effects of using Medical Marijuana, and there may be associated health risks.
Symptoms of Medical Marijuana overdose include but are not limited to nausea, vomiting and disturbances to heart rhythm.
The scientific basis for the medical use of Medical Marijuana is not complete. There is little known regarding how Medical Marijuana may, or may not, react with other pharmaceutical or herbal medications.
The use of Medical Marijuana may affect coordination, cognition, and judgment. While under the influence of Medical Marijuana, do not to drive, operate machinery, or engage in potentially hazardous activities.
The possibility exists that Medical Marijuana may exacerbate schizophrenia in persons predisposed to that disorder.
I have never had symptoms of schizophrenia or have been diagnosed as having schizophrenia by a physician or mental health professional.
I have no direct blood relatives (father, mother, siblings) that have had symptoms or has been diagnosed as having schizophrenia or has been psychotic.
I agree to tell my medical professional if I have ever had symptoms of schizophrenia, been psychotic or attempted suicide. I also agree to tell my medical professional if I have ever been prescribed or taken medicine for any of these problems.
I understand that my medical professional does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition.
Women should not consume Medical Marijuana while planning to become pregnant, during pregnancy, or while breastfeeding, except on the advice of the certifying health practitioner, and in the case of breastfeeding mothers, on the advice or the infant’s pediatrician.
I am not pregnant, intending on becoming pregnant, or breastfeeding. ( N/A if male)
Medical Marijuana while under the influence of alcohol is not recommended.
I understand that side effects may occur while I am taking Medical Marijuana.
In the event that I experience an adverse reaction, I am advised to contact my medical professional. In the event my medical professional is not available, I agree to call 911 for help and I am advised to lie down, relax, and rest until help arrives.
I agree to tell my medical professional if I have ever had symptoms of schizophrenia, been psychotic or attempted suicide. I also agree to tell my medical professional if I have ever been prescribed or taken medicine for any of these problems.
I am over 18 years of age and understand the requirements of the State of Florida’s Medical Marijuana program
I have been advised of the current state of knowledge in the medical community of the effectiveness of Medical Marijuana for the treatment of my condition.
I have been advised of the potential risks and side effects of using Medical Marijuana.
When under the influence and/or in possession of Medical Marijuana in public, your state issued Medical Marijuana ID Card or temporary state issued verification should be on your person at all times.
I understand if I give dishonest or untruthful information, I will be deactivated as a patient.
I understand there are certain requirements to remain in compliance with Florida law regarding Medical Marijuana. Some of these requirements include (but are not limited to)
  • Medical records confirming condition obtaining medical marijuana as treatment
  • Regularly scheduled follow-ups at intervals determined by state law
  • Eforce prescription check
I understand that the Florida Department of Health may revoke your Medical Marijuana Use Registry identification card for any of the following:
  • The patient or legal representative makes material misrepresentations in his or her application.
  • The patient uses his or her card to obtain cannabis for another individual
  • The legal representative purchases, obtains, possesses, or uses cannabis not sold by an approved dispensing organization.
  • The patient is no longer a qualified patient.
I understand that possession or use of Medical Marijuana is unlawful under Federal law and outside of the state of Florida. I also understand that possession or use of Medical Marijuana is unlawful within the state of Florida if not recommended for medical purposes by a licensed medical doctor with the legal ability to do so.
I hereby acknowledge Miracle Leaf Health Centers , and its employees are not addressing specific aspects of my medical care nor are any of them my primary care provider. Furthermore, I, for myself, my heirs, assigns, or anyone acting on my behalf, hold Miracle Leaf Health Centers , and its principals, agents, and employees free of and harmless from any responsibility for any harm resulting to me and/or other individuals because of my Medical Marijuana use.
I certify that I fully understand the potential risks and side effects related to the use of Medical Marijuana as described above.
In using Medical Marijuana, I fully accept responsibility and assume the risks and side effects associated with its use.
I agree that Miracle Leaf Health Centers and its employees shall not be held responsible for any harm resulting to me and/or any other individuals) because of my use of Medical Marijuana.
I certify that I have read this document and declare under penalties of perjury that the information contained herein is true, correct, and complete.
I attest the information on this consent form is correct and any medical history present or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intent to use my physicians recommended order for the purpose of illegally obtaining medical marijuana. Solely for medical purposes I allow Miracle Leaf Health Centers to converse of my medical condition.
I affirm I have a serious medical condition that negatively affects my quality of life. I have or I am interested in finding out whether or not medical marijuana provides substantial relief and improvement of my condition.
Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise, demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against non insured physicians who fail to satisfy adverse judgements arising from claims of medical malpractice. This notice provided pursuing to Florida law.
I am a patient of MIRACLE LEAF HEALTH CENTERS. My evaluating physician has asked for agreed for Miracle Leaf Health Centers to be the care provider for regarding consultations, referrals and recommended orders.
I have read and understand the foregoing disclosures and have initialed next to each to acknowledge this understanding.
STEP 5 - PLEASE INITIAL MEDICAL MARIJUANA CONSENT FORM
A qualified physician may not delegate the responsibility of obtaining written informed consent to another person. The qualified patient or the patient’s parent or legal guardian if the patient is a minor must initial each section of this consent form to indicate that the physician explained the information and, along with the qualified physician, must sign and date the informed consent form.
a. The Federal Government’s classification of marijuana as a Schedule I controlled substance.
The federal government has classified marijuana as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (1) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states, such as Florida, which have modified their state laws to treat marijuana as a medicine.

When in the possession or under the influence of medical marijuana, the patient or the patient’s caregiver must have his or her medical marijuana use registry identification card in his or her possession at all times.
b. The approval and oversight status of marijuana by the Food and Drug Administration.
Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore, the “manufacture” of marijuana for medical use is not subject to any federal standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients, which may vary in potency, impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.
c. The potential for addiction.
Some studies suggest that the use of marijuana by individuals may lead to a tolerance to, dependence on, or addiction to marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should contact Dr. Miami - Miracle Leaf (name of qualified physician).
d. The potential effect that marijuana may have on a patient’s coordination, motor skills, and cognition, including a warning against operating heavy machinery, operating a motor vehicle, or engaging in activities that require a person to be alert or respond quickly.
The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. Driving under the influence of cannabis can double the risk of crashing, which escalates if alcohol is also influencing the driver. While using medical marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly and I should not participate in activities that may be dangerous to myself or others. I understand that if I drive while under the influence of marijuana, I can be arrested for “driving under the influence.”
e. The potential side effects of medical marijuana use.
Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, may affect the production of sex hormones that lead to adverse effects, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of medical marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. Many medical authorities claim that use of medical marijuana, especially by persons younger than 25, can result in long-term problems with attention, memory, learning, drug abuse, and schizophrenia.
I understand that using marijuana while consuming alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.
I agree to contact Miami - Miracle Leaf if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact Dr. Miami - Miracle Leaf if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.
f. The risks, benefits, and drug interactions of marijuana.
Signs of withdrawal can include: feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.
Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to contact Dr. Miami - Miracle Leaf immediately or go to the nearest emergency room.
Numerous drugs are known to interact with marijuana and not all drug interactions are known. Some mixtures of medications can lead to serious and even fatal consequences. I agree to follow the directions of Dr. Miami - Miracle Leaf regarding the use of prescription and non-prescription medication. I will advise any other of my treating physician(s) of my use of medical marijuana.
Marijuana may increase the risk of bleeding, low blood pressure, elevated blood sugar, liver enzymes, and other bodily systems when taken with herbs and supplements. I agree to contact Dr. Miami - Miracle Leaf immediately or go to the nearest emergency room if these symptoms occur.
I understand that medical marijuana may have serious risks and may cause low birthweight or other abnormalities in babies. I will advise Dr. Miami - Miracle Leaf if I become pregnant, try to get pregnant, or will be breastfeeding.
g. The current state of research on the efficacy of marijuana to treat the qualifying conditions set forth in this section.
Cancer
  • There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancers, including glioma.

    There is evidence to suggest that cannabinoids (and the endocannabinoid system more generally) may play a role in the cancer regulation processes. Due to a lack of recent, high quality reviews, a research gap exists concerning the effectiveness of cannabis or cannabinoids in treating cancer in general.


  • There is conclusive evidence that oral cannabinoids are effective antiemetics in the treatment of chemotherapy-induced nausea and vomiting.

    There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancer-associated anorexia-cachexia syndrome and anorexia nervosa.
Epilepsy
  • There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for epilepsy.

    Recent systematic reviews were unable to identify any randomized controlled trials evaluating the efficacy of cannabinoids for the treatment of epilepsy. Currently available clinical data therefore consist solely of uncontrolled case series, which do not provide high-quality evidence of efficacy. Randomized trials of the efficacy of cannabidiol for different forms of epilepsy have been completed and await publication.
Glaucoma
  • There is limited evidence that cannabinoids are an ineffective treatment for improving intraocular pressure associated with glaucoma.

    Lower intraocular pressure is a key target for glaucoma treatments. Nonrandomized studies in healthy volunteers and glaucoma patients have shown short-term reductions in intraocular pressure with oral, topical eye drops, and intravenous cannabinoids, suggesting the potential for therapeutic benefit. A good-quality systemic review identified a single small trial that found no effect of two cannabinoids, given as an oromucosal spray, on intraocular pressure. The quality of evidence for the finding of no effect is limited. However, to be effective, treatments targeting lower intraocular pressure must provide continual rather than transient reductions in intraocular pressure. To date, those studies showing positive effects have shown only short-term benefit on intraocular pressure (hours), suggesting a limited potential for cannabinoids in the treatment of glaucoma.
Positive status for human immunodeficiency virus
  • There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS.

    There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as effective treatments for AIDS wasting syndrome.
Acquired immune deficiency syndrome
  • There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS.

    There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as effective treatments for AIDS wasting syndrome.
Post-traumatic stress disorder
  • There is limited evidence (a single, small fair-quality trial) that nabilone is effective for improving symptoms of posttraumatic stress disorder.

    A single, small crossover trial suggests potential benefit from the pharmaceutical cannabinoid nabilone. This limited evidence is most applicable to male veterans and contrasts with non-randomized studies showing limited evidence of a statistical association between cannabis use (plant derived forms) and increased severity of posttraumatic stress disorder symptoms among individuals with posttraumatic stress disorder. There are other trials that are in the process of being conducted and if successfully completed, they will add substantially to the knowledge base.
Amyotrophic lateral sclerosis
  • There is insufficient evidence that cannabinoids are an effective treatment for symptoms associated with amyotrophic lateral sclerosis.

    Two small studies investigated the effect of dronabinol on symptoms associated with ALS. Although there were no differences from placebo in either trial, the sample sizes were small, the duration of the studies was short, and the dose of dronabinol may have been too small to ascertain any activity. The effect of cannabis was not investigated.
Crohn’s disease
  • There is insufficient evidence to support or refute the conclusion that dronabinol is an effective treatment for the symptoms of irritable bowel syndrome.

    Some studies suggest that marijuana in the form of cannabidiol may be beneficial in the treatment of inflammatory bowel diseases, including Crohn’s disease.
Parkinson’s disease
  • There is insufficient evidence that cannabinoids are an effective treatment for the motor system symptoms associated with Parkinson’s disease or the levodopainduced dyskinesia.

    Evidence suggests that the endocannabinoid system plays a meaningful role in certain neurodegenerative processes; thus, it may be useful to determine the efficacy of cannabinoids in treating the symptoms of neurodegenerative diseases. Small trials of oral cannabinoid preparations have demonstrated no benefit compared to a placebo in ameliorating the side effects of Parkinson’s disease. A seven-patient trial of nabilone suggested that it improved the dyskinesia associated with levodopa therapy, but the sample size limits the interpretation of the data. An observational study demonstrated improved outcomes, but the lack of a control group and the small sample size are limitations.
Multiple sclerosis
  • There is substantial evidence that oral cannabinoids are an effective treatment for improving patient-reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on clinician-measured spasticity.

    Based on evidence from randomized controlled trials included in systematic reviews, an oral cannabis extract, nabiximols, and orally administered THC are probably effective for reducing patient-reported spasticity scores in patients with MS. The effect appears to be modest. These agents have not consistently demonstrated a benefit on clinician-measured spasticity indices.
Medical conditions of same kind or class as or comparable to the above qualifying medical conditions
  • The qualifying physician has provided the patient or the patient’s caregiver a summary of the current research on the efficacy of marijuana to treat the patient’s medical condition.
  • The summary is attached to this informed consent as Addendum_____.
Terminal conditions diagnosed by a physician other than the qualified physician issuing the physician certification
  • The qualifying physician has provided the patient or the patient’s caregiver a summary of the current research on the efficacy of marijuana to treat the patient’s terminal condition.
  • The summary is attached to this informed consent as Addendum_____.
Chronic nonmalignant pain
  • There is substantial evidence that cannabis is an effective treatment for chronic pain in adults.

    The majority of studies on pain evaluated nabiximols outside the United States. Only a handful of studies have evaluated the use of cannabis in the United States, and all of them evaluated cannabis in flower form provided by the National Institute on Drug Abuse. In contrast, many of the cannabis products that are sold in state-regulated markets bear little resemblance to the products that are available for research at the federal level in the United States. Pain patients also use topical forms.

    While the use of cannabis for the treatment of pain is supported by wellcontrolled clinical trials, very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.
h. That the patient’s de-identified health information contained in the physician certification and medical marijuana use registry may be used for research purposes.
The Department of Health submits a data set to The Medical Marijuana Research and Education Coalition for each patient registered in the medical marijuana use registry that includes the patient’s qualifying medical condition and the daily dose amount and forms of marijuana certified for the patient.

I have had the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that Dr. Miami - Miracle Leaf has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana.

Dr. Miami - Miracle Leaf also informed me of the risks, complications, and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that Dr. Miami - Miracle Leaf informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits.

Patient Signature (or signature of the Parent or legal Guardian If the Patient is a Minor.)

Dr. Miami - Miracle Leaf has explained the information in this consent form about the medical use of marijuana.
Use your mouse or finger to sign below. Click "Add Signature" after signing.

Qualified Physician Signature

I have explained the information in this consent form about the medical use of marijuana to   .
Use your mouse or finger to sign below. Click "Add Signature" after signing.

Witness Signature

Use your mouse or finger to sign below. Click "Add Signature" after signing.
STEP 6 - INFORMED CONSENT FOR TELEMEDICINE/ TELEHEALTH SERVICES CONSULTATION

Name of Patient Receiving Telehealth Services:________________________________ Date of Birth: _______________________

Telemedicine/Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient and the healthcare provider. An originating site is the location of the patient beneficiary. The distant site is where the physician or providers of Telemedicine/Telehealth are residing during the time of the consultation.

I understand that as with any medical procedure, there are expected benefits and potential risks associated with the use of Telemedicine/Telehealth that I need to be aware of:

Expected Benefits include the following:

  • Improved access to care by enabling a patient to remain at a remote site while receiving professional care from a healthcare provider
  • More efficient medical and health evaluation and management.
  • Patients may be diagnosed and treated earlier which can contribute to improved outcomes and less costly treatments

Possible Risks include, but are not limited to:

  • Despite reasonable safeguarding efforts, the transmission of my medical information could be disrupted or distorted by technical failures resulting in delays in evaluation; the transmission of my medical information could be interrupted by unauthorized person; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
  • Telemedicine/Telehealth based services may not be as complete as face-to-face services. I understand that if my Telemedicine/Telehealth provider believes that I will be better served by another form services (e.g. face-to-face services) I will be referred to another provider and it is my responsibility to ensure that referral instructions are followed timely.
  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the Telemedicine/Telehealth healthcare provider.
  • In rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare cases, a lack of access to complete and/or accurate medical records or information may result in adverse drug reactions, allergic reaction, or other judgment error

By signing this form, I understand the following:

  • I am a patient of MIRACLE LEAF HEALTH CENTERS. My evaluating physician has asked Miracle Leaf Health Centers to be the care provider to provide a Telemedicine/Telehealth consultation.
  • I understand that alternative methods of medical/health care may be available to me including face-to-face interaction, and that I may choose another alternative at any time.
  • I give my consent for the sharing of personal health information with Miracle Leaf Health Centers and its physicians/providers.
  • I understand that I have the right to withhold or withdraw my consent to the use of Telemedicine/Telehealth in the course of my care at any time without affecting my right to future care or treatment.
  • I understand that I may expect the anticipated benefits from the use of telemedicine/telehealth in my care, but that no results can be guaranteed or assured.
  • I understand that I may expect the anticipated benefits from the use of telemedicine/telehealth in my care, but that no results can be guaranteed or assured.
  • The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and vulnerable adult abuse.
  • Any cause of action arising out of this service must do so exclusively in Miami, Florida, United States of America, and I knowingly waive my right to access any other legal forum.

I have read and understand the information provided above regarding Telemedicine/Telehealth and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telemedicine/Telehealth in my medical/ health care.

STEP 7 - ADD ELECTRONIC SIGNATURE

By electronically signing this document, YOU DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.

Please sign using a stylus, your mouse, or your finger below to sign this document. After the document is signed, you can proceed to print it or save it as PDF.

×

UPLOAD YOUR DRIVERS LICENSE OR STATE ID

Upload
Uploading
×

UPLOAD YOUR DRIVERS LICENSE OR STATE ID

Uploading
×

Upload Your Photo

Upload
Uploading
×

Upload Your Photo

Uploading