top of page
Missouri
Medical Marijuana
Certification
MOONDANCE MEDICAL SPECIALTIES
Home
About Dr. Brayfield
Assessment
FAQ
Contact Us
Blog
More
Use tab to navigate through the menu items.
Moondance Medical Qualification Form
Preferred Phone Number
Type of phone number:
*
Cell Phone
Home Phone
Other
Preferred Method of Communication:
*
Email
Cell Phone Text Messaging
Home Phone
Any of the above
Mailing Address (if different than physical address):
How did you find us?
*
Referred from a friend
Google/Search Engine
Doctor Referral
Other:
Qualifications
Are you a current Missouri Resident?
*
Yes
No
Do you have a valid Missouri Drivers License or Photo I.D.?
*
Yes
No
No, but the patient has a valid out of state I.D., passport, or other photo I.D. with proof of residency (bank statement, utility bill, etc.)
Are you 18 years of age or older?
*
Yes
No
No, but the Patient is below 18 years of age and will be accompanied by a parent or legal guardian
Do you currently have medical records and/or documentation from a primary care physician or specialist describing the diagnosis?
*
Yes, they are in the Patient's Possession
Yes, but they are with the patient's primary physician
Yes, but not sure where they are located
No, patient does not have any medical records
When did this health issue(s) begin? (You may enter an approximate month/year if the exact time is unknown)
Are you currently receiving care for your applicable condition(s) by another physician?
*
Yes
No
Are you pregnant or breastfeeding
*
Yes
No
N/A
Are you now or have been treated for Bipolar or Schizophrenia?
*
Yes
No
Are you currently seeing a Physician?
*
Yes
No
Physician's Phone Number
Is the patient currently on probation or parole?
*
Yes
No
Has the patient ever been arrested or convicted for a crime relating to marijuana specifically drug trafficking?
*
Yes
No
Does the patient have a current CDL (commercial driver's license)?
*
Yes
No
Do you have any other federal licenses (eg. pilot's license, government security clearances, etc.)?
*
Yes
No
Have you been recommended medical marijuana in the past?
*
Yes
No
Intake Form
Referred By:
*
Self
Other:
Emergency contact phone number
Medications
Are you currently taking any prescription medications?
*
Yes
No
Symptoms/Conditions
What condition do you have that you believe medical marijuana would help?
Your Symptoms (check all that apply)
Migraine
Glaucoma
Weight loss
Seizures
Anxiety
Depression
Nerve pain
Back Pain
Neck Pain
Difficulty Breathing
Cough for more than 6 weeks
Mood Swings
Sleep Problems
Arthritis
Other (please explain below)
Your Medical Hx please list any medical problems that you have had or now have
Nicotine Use
Nicotine Use
*
Use Currently
In the past but quit
Never
If you use other forms of nicotine please describe your usage per day
Chronic Pain
Have you had persistent pain for more than six weeks?
*
Yes
No
Does your pain Interfere with pleasurable activity?
Yes
No
Does your pain limit your ability to work?
Yes
No
Did you have any surgery specifically for your pain (please list)?
Have you had Nerve Blocks/Epidural?
Yes
No
Have you had Osteopathic/Chiropractic treatment?
Yes
No
Have you had Physical Therapy?
Yes
No
Have you had TENS (transcutaneous electrical nerve stimulator)?
Yes
No
Have you had Acupuncture?
Yes
No
Comments
Send
Thanks for submitting!
bottom of page
