Marital Status SingleMarriedDivorcedWidowed Sex MaleFemale
Name DOB S.S.# (last 5 digits) XXX-X Address City, ST, Zip TX Phone Cell Email Spouse’s Name Spouse’s Phone
Employer/Occupation Full TimePart Time Did you serve in the US Armed Forces? (If yes, which branch of the military?) YesNo
Name of person NOT living with you Relationship Address City, ST, Zip TX Phone Cell
Assignment of Benefits | Financial Agreement
I hereby give lifetime authorization for payment to be made directly to Dr. Darryl Camp at Texas Herbal Clinic, PLLC and any assisting physicians for services rendered. I understand that I am financially responsible for all charges. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits.I further agree that a photocopy of this agreement shall be as valid as the original.
Signature Date
Please list your past or present medical conditions
Diabetes High Blood Pressure High Cholesterol Stroke Heart Disease or Heart Attack Aneurysm Tuberculosis Hepatitis AIDS or HIV Cancer (if yes, what type) Kidney Disease Bleeding Ulcers Uveitis Glaucoma Rheumatoid Arthritis Other Medical Problems Other Other Other Other
Please list any ORTHOPAEDIC SURGERIES you have had
1. Date 2. Date 3. Date 4. Date
Please list any JOINT or SPINAL INJECTIONS you have had
Please list any OTHER SURGERIES you have had
Are you allergic to any medication YesNo
Please list ALL medications you currently take (if necessary, use back for additional space)
Medicine Dose How many times daily
Are you currently on Methadone or Suboxone? YesNo
If YES, please list the name of the Methadone or Suboxone Clinic where you are seeking treatment. In order to qualify for evaluation for Medical Cannabis, we will need to discuss your care with you and your clinic to ensure that you are receiving the proper treatment. You have come far in your recovery and we want to ensure that you continue to recover and make a smooth transition with Medical Cannabis. (*You will need to ask the Methadone Clinic to release a note to us stating that you are under their care. This is not optional if you wish to become a patient of Medical Cannabis.
NAME ANY SPECIALIST PHYSICIANS YOU SEE, THEIR SPECIALTY, AND WHY YOU SEE THEM
Do you have any past medical history or problems (i.e. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition?
IF YOU HAVE BEEN ADMITTED TO DRUG/ALCOHOL REHAB THIS WOULD BE HELPFUL TO KNOW IF YOU HAD A STROKE AND WERE ADMITTED TO A REHAB FACILITY FOR SEVERAL WEEKS TO REGAIN MOBILITY PLEASE LIST THAT HERE.
FAMILY HISTORY OF MEDICAL PROBLEMS
PLEASE LIST MEDICAL CONDITIONS THAT RUN IN YOUR FAMILY (PARENTS, BROTHERS/SISTERS, AUNTS/UNCLES, ETC.)
WOMEN ONLY- Are you currently pregnant and/or breastfeeding? (PLEASE NOTE: If you are pregnant, a dispensary will notify our office and you will not be able to receive medical cannabis until after you deliver your baby and/or stop breastfeeding)
YesNo
This helps to better understand you. Your answers do NOT disqualify you from becoming a medical cannabis patient.
Do you CURRENTLY smoke? YesNo If YES, how many packs per day? For how many years?
If you don’t currently smoke, did you smoke in the past? YesNo If YES, how long ago did you quit? Before you quit, how many packs per day did you smoke? Before you quit, how many years did you smoke?
Do you CURRENTLY drink alcohol? YesNo If YES, how many days per week? How many drinks do you have when you drink?
Do you CURRENTLY use any of the following drugs?
Cocaine YesNo Speed or Amphetamines YesNo Heroin/Opium/Morphine YesNo Designer Drugs YesNo Other
Have you ever used Marijuana? YesNo Do you currently use Marijuana? (THERE IS NO PENALTY FOR ANSWERING ‘YES’) YesNo If currently using Marijuana, how often do you use/medicate?
HERE YOU WILL BE ASKED TO DESCRIBE YOUR PAIN AND HOW IT AFFECTS YOUR DAILY LIFE. IF THERE ARE ANY QUESTIONS THAT DO NOT PERTAIN TO YOU, YOU DO NOT HAVE TO ANSWER THEM.
Do you use over the counter medication for pain? (like Tylenol, Advil, Aleve, Motrin, Aspirin) YesNo How well does over the counter medication, like those mentioned above, help with your pain? It helps to manage minimal aches and pains, like headachesIt helps to take the edge off of the painIt helps to take the edge off of the pain, but I need to take it several times per dayIt does not really help at all with my pain
Check any of the following pain medications that have helped (or are helping) with your pain: Hydrocodone (Vicodin)OxycontinPercocetMS ContinFentanylGabapentin (Neurontin)CodeineOpanaHydromorphoneLyricaDilaudidOxycodone
SEVERITY: Please rate your pain with “0” = NO PAIN and “10” = PAIN REQUIRING IMMEDIATE ER VISIT
How much pain do you experience when you wake up in the morning? 12345678910 How much pain do you experience at the end of the day/at night? 12345678910 How much pain do you experience when you try to exercise? 12345678910 How much pain do you experience when you walk up and down stairs? 12345678910
How often does your pain limit you from doing things you normally like to do? (i.e. going on family outings, shopping, spending time with friends, etc.) NeverMost of the timeRarelyA lot of the timeSometimesAll of the time
THANK YOU FOR COMPLETING THIS INTAKE FORM.
TEXAS HERBAL CLINIC
(713) 955-3325
1. We recommend that you call your PCP/Specialist and ask if they can fax ONLY your last 1-2 office visit notes to us at 832-831-1882 ASAP so that we can compile your chart. Any delay in receiving your records will delay your visit with us. DO NOT ASK FOR “ALL MY RECORDS”.
2. YOU WILL NEED TO PAY AT THE TIME OF YOUR NEW PATIENT CONSULTATION OR ESTABLISHED PATIENT VISIT. If you are unable, please let us know so that we can schedule you for your telemedicine consultation at a later date. ([email protected]).
3. After your initial consultation appointment you will be placed on the CURT (Compassionate Use Registry of Texas) registry by our clinic and the appropriate prescription completed electronically. The prescription will be accessible and verified by the dispensary. You, the patient, may order from any Texas dispensary of your choice. We recommend texasoriginal.com. They will work with you for appropriate products based on the prescription as well as pick up or shipping.
