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Missouri
Medical Marijuana
Certification
MOONDANCE MEDICAL SPECIALTIES
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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
*
required
Mailing Address (if different than physical address):
How did you find us?
*
Referred from a friend
Google/Search Engine
Doctor Referral
Other:
Qualifications
Do you have a government issued Photo I.D. such a drivers license, passport or military ID?
*
Yes
No
When did this health issue(s) begin? (You may enter an approximate month/year if the exact time is unknown)
*
required
Are you currently receiving care for your applicable condition(s) by another physician?
*
Yes
No
Are you pregnant or breastfeeding
*
Yes
No
N/A
Physician's Phone Number
Is the patient currently on probation or parole?
*
Yes
No
Do you have a federal clearance, pilots license or other federal license?
*
Yes
No
Have you held a Missouri Medical Marijuana lincense now or in the past?
*
Yes
No
Intake Form
Emergency contact phone number
Medications
Are you currently taking any prescription medications?
*
Yes
No
List medications, name only
Symptoms/Conditions
Your Symptoms (check all that apply)
*
Required
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 history 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? (If no, please proceed to next section)
*
Yes
No
Does your pain limit your ability to work?
Yes
No
Does your pain Interfere with pleasurable activity?
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
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