Appointments for your Ohio Medical Marijuana Card evaluation are available to Ohio residents only. Name(Required) First Name Middle Initial Last Name Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Female Male Marital Status(Required) Single Married Domestic Partner Separated Divorced Widowed Street Address(Required) City(Required) State(Required) Zip Code(Required) Email(Required) Driver's License Number(Required) Mobile NumberHome PhoneWork PhonePrefered Contact Method Mobile Phone Home Phone Work Phone Email 1. OHIO MEDICAL MARIJUANA CONTROL PROGRAM QUALIFYING CONDITIONS AIDS ALS Alzheimer’s Disease Cancer CTE Chron’s Disease Ulcerative Colitis Fibromyalgia Glaucoma Hepatitis C Inflammatory Bowel Disease Multiple Sclerosis Chronic Pain Parkinson’s Disease HIV PTSD Sickle Cell Anemia Spinal Cord Disease/Injury Tourette’s Syndrome Traumatic Brain Injury Epilepsy Other Seizure Disorder Please select the qualifying condition(s) for which you seek a recommendation for treatment with medical marijuana:2. What standard medical treatment have you attempted for these conditions?3. MEDICAL HISTORY Headaches Heartburn Depression Thyroid Disease Gastrointestinal Bleeding Osteoporosis Kidney Stones Pneumonia Heart Disease Arthritis Hearing Loss Urinary Tract Infection Blood Clots Asthma Diabetes High Cholesterol Gout High Blood Pressure Stroke Stomach Ulcers Anxiety Macular Degeneration Hepatitis (A, B, C) Please check all the conditions which you currently have or have had in the past:4. DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS? Recent Weight Gain Joint Swelling Difficulty Swallowing Frequent/Painful Urination Constipation Fainting Poor Concentration Ringing in Ears Loss of Vision Rash Difficulty Sleeping Recent Weight Loss Joint Pain Heart Palpitations Blood in Urine Diarrhea Dizziness Anxiety Night Sweats Chest Pain Stomach Pain Hallucinations Numbness Frequent Sore Throat Shortness of Breath Nausea Memory Loss Poor Appetite Depression Muscle Weakness Numbness/Tingling None of the Above 5. DO YOU USE ANY OF THE FOLLOWING? Tobacco Alcohol Illicit Drugs (Not Marijuana) None 6. Have you ever used marijuana during the same period in which you have had your qualifying conditions? Yes No 7. LIST MEDICATION ALLERGIES/REACTIONS8. LIST CURRENT MEDICATIONS AND DOSAGE9. LIST ANY NON-PRESCRIPTION MEDICINES OR SUPPLEMENTS YOU ARE CURRENTLY TAKING10. Have you received or are you currently receiving treatment from any of the following for your medical condition(s) for which you seek a recommendation for medical marijuana? Physical Therapist Social Worker Orthopedist Massage Therapist Oncologist Psychiatrist Endocrinologist Chiropractor Heart Specialist Pain Specialist Neurologist Acupuncturist Other None 11. List doctors you have seen in the last two years for reasons related to qualifying condition(s) for which you seek a recommendation for treatment with medical marijuana. We will not contact your doctor without your written consent.12. List any surgeries you have had.My signature below attests to the fact that I have accurately and completely disclosed the requested information and indicated that I give permission to AccuDoc Inc PC (dba”AMMJD”) to disclose any information regarding my treatment to Ohio’s Medical Marijuana Control Program so that I can be registered as an active medical cannabis patient. Client Signature(Required) 63203
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