16 Van Cott Rd #2e, Deer Park, NY 11729

  Contact : 631.274.0777

Medical Marijuana Patient Information Form

Diagnosis-18 years and over-CHECK ALL THAT APPLY

Cancer (If checked, please specify type in field below)Chronic PainMultiple SclerosisCrohn’s DiseaseComplex Regional Plan SyndromeGlaucomaEpilepsyPTSDHIV/AIDSCachexiaSickle Cell DiseaseCerebral PalsyParkinson’s DiseaseWasting SyndromeUlcerative ColitisCystic FibrosisSevere Psoriasis & Psoriasis ArthritisAmyotrophic Lateral SclerosisNerve Tissue Damage of Spinal Cord/SpasticityPost Laminectomy Syndrome with Chronic RadiculopathyPalliative Care/Terminal Illness requiring End-of-lifeUncontrolled intractable Seizure DisorderIrreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Diagnosis-18 years and over-CHECK ALL THAT APPLY

Chronic PainCerebral PalsySevere EpilepsyIrreversible Spinal Cord Injury with Intractable SpasticityCystic FibrosisUncontrolled SeizuresTerminal End-of-Life Care

Symptoms You are Experiencing

Chronic PainAnxietyDizzinessStomach AcheConstipationJoint PainBlurred VisionLoss of AppetiteSkin RashesHeadacheAcid Reflux/HeartburnWeight GainDepressionNeck or Back painAbdominal CrampsChronic CoughUrinary ProblemsShooting Pain (Nerve)Muscle PainNausea/VomitingTremorsInsomnia/Sleeping Disorder (falling or staying asleep)Numbness/Tingling in Fingers and ToesOther

Time Spent Experiencing Symptoms

What have you tried to alleviate the symptoms? CHECK ALL that apply below

AcupunctureChiropractorPhysical TherapyMassage TherapyReikiAyurvedic MedicineOther

Your Current Physician