Questionnaire
PATIENT INFORMATION
First Name
Middle Name
Last Name
Gender
Address
Address 2
City
State
Zipcode
County
Height
Weight
Social Security #
Drivers Lic. / ID #
Phone
Email
MEDICAL INFORMATION
SYMPTOMS
MISSOURI medical cannabis qualifying conditions shown below:
Check each medical problem that you suffer from or check other to have the doctor evaluate your unique condition. At least one box must be checked to qualify.
PATIENT MEDICAL HISTORY
Immediate family medical issues
(Indicate if you or your immediate family had any of the following problems)
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UPLOAD MEDICAL RECORDS
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Risks/Consent

You must be eighteen (18) years of age to make an appointment with Purpose Medical. Thus, if you are under the age of eighteen (18) STOP now, and do not access or use this website. Should you make an appointment, your consulting physician will discuss the risks, side effects, and potential benefits of marijuana use for you individually. Although you may have the right to access medical marijuana in Article XIV, Section 1 of the Missouri Constitution, marijuana is a schedule I controlled substance under the federal Controlled Substances Act. Consequently, possession, distribution, cultivation, and manufacture of marijuana are illegal under federal law. Upon acceptance of this agreement, you represent and warrant that you understand the legal risks associated with your use of marijuana for medical treatment, including arrest and prosecution under federal laws. Should any criminal or civil administrative or legal actions be instituted against you for your use or possession of marijuana for medical treatment as recommended by a physician you select through Purpose Medical, you will not hold Purpose Medical or any of its consulting physicians liable for any loss, injury, or claims of any kind resulting from those actions. You are solely responsible for maintaining a full understanding of the medical marijuana laws in Missouri. All evaluations by our consulting physicians comply with the guidelines regarding medical marijuana laws in Missouri. Physicians affiliated with Purpose Medical are in no way obligated to recommend to you the use of marijuana for your medical treatment and neither Purpose Medical nor its consulting physicians make any warranties or guarantees that the use of medical marijuana would be an effective treatment for your medical conditions. Purpose Medical and its consulting physicians do not in any way engage in the cultivation, manufacture, distribution, or sale of marijuana. Purpose Medical and its consulting physicians cannot assist you at any time or in any way in the procurement of any marijuana for your consumption, possession, sale or distribution, cultivation, or manufacture of marijuana for medical use or otherwise. Should a physician determine that you have a qualifying medical condition to justify a medical marijuana recommendation, you bear the sole responsibility of obtaining cannabis for your medical use within Missouri. Under no circumstances may you bring marijuana, any marijuana derivatives, marijuana products, or marijuana paraphernalia on to Purpose Medical premises. By scheduling an appointment with Purpose Medical, you acknowledge that you have read and understand these legal disclaimers.

PATIENT SIGNATURE
By electronically signing this document, you declare under penalty of perjury that the information on this form is true and correct.
Additionally, you are also aware that your recommendation may be revoked at any time if you have perjured or misrepresented yourself on this form.
Note: Filling out this questionnaire does not guarantee a medical marijuana recommendation.
Please sign below using a stylus, your mouse, or your finger and then click “Add Signature”