PATIENT QUESTIONNAIRE

PATIENT INFORMATION
Legal Name: _______________________________________________________________________________________
Date of Birth: _________________________ Occupation/Trade: ____________________________________________
Address: __________________________________________________________________________________________
City: ____________________________________________________ State: ___________ Zip: __________________
Primary phone: _________________________ Email address: ______________________________________________
How did you hear about us? ___________________________________________________________________________

MEDICAL HISTORY
Age: ________ Height: ________ Weight: ________ Gender: ________
Qualifying Medical Complaints: (Describe the qualifying conditions for which you would like to use cannabis; include year of
onset. Qualifying conditions are: intractable pain, multiple sclerosis, cancer, HIV, hepatitis C, Crohns, epilepsy, glaucoma, chronic renal failure,
anorexia, and other diseases which result in nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle spasms, or spasticity. If you do not
see your condition listed, you DO NOT have a qualifying condition and are not eligible for an authorization. )

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you discussed any of these complaints with a medical care provider? (Include doctors, chiropractors, acupuncturists, etc.)
No

Yes

When did you last see your medical care provider?__________________________________________

Doctor:________________________________ Date(s): ________________ Condition: ___________________________

Doctor:________________________________ Date(s): ________________ Condition: ___________________________
Did you bring medical records with you today? Yes

No (If no, please fill out the records release form on page 4.)

Medications: (List all prescriptions and over-the-counter medications you are taking for your complaints.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other Treatments: (Any other treatments you use now or have tried for your medical complaints.)
Surgery

Physical Therapy

Massage

Chiropractor

Acupuncture

Herbs or Vitamins: (List) ___________________________________________________________________________

Exercise: (Type) _________________________________________________________________________________
Other: __________________________________________________________________________________________

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Please indicate your most effected areas in the figures:

Surgical History: (List any major operations/surgeries and dates.)

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Additional Medical History: (Please check all that apply. Note that not all the conditions listed in the following list represent the
legal qualifying conditions. This is general health information for our health care professionals to better serve you.)

ADD/ADHD
Alcoholism
Anemia
Asthma
Cancer
Cramping
Crohns Disease
Diabetes
Eating Disorders/Weight Loss
Fibromyalgia
Glaucoma

Headaches/Migraines
Heart Disease
Hepatitis
Hernia
High Blood Pressure
HIV or AIDS
Intestinal Disorders (ulcers, IBS,
diarrhea, etc.)
Joint Pain
Kidney Disease
Multiple Sclerosis

Muscle Spasms
Nausea/Vomiting
Painful Menstruation
Psychiatric Disorders (anxiety,
depression, etc.)
Seizures/Epilepsy
Sinus Issues
Sleep Disorders (apnea, insomnia)
STDs
Stroke/Paralysis
Thyroid Issues

Family History: (Is there a history of any medical conditions in your family?) __________________________________________
_______________________________________________________________________________________________________________________________________

Female Patients: Are you currently pregnant? No

Are you planning on becoming pregnant? No

Yes

Yes

Are you breastfeeding? No

Yes

Are you using contraception? No

Yes

Drug and Alcohol Use History:

Do you use tobacco? No

Yes Amount? __________________________________________________________

Do you use alcohol? No

Yes Amount? __________________________________________________________

Do you use other non-prescribed drugs? No

Have you ever been in drug rehab? No

206.466.1766

Yes Describe: __________________________________________

Yes Describe: ______________________________________________

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CANNABIS HISTORY
Have you received a medical cannabis recommendation before? No

Yes

Date: ______________________________ Condition: _____________________________________________________

Doctor/Clinic: ______________________________________________________________________________________
Do you currently use cannabis? No (skip rest of section)
How often? Every day or almost every day
Preferred method? Smoke

Vaporize

Yes

A few times a week

Ingest

How effective is it for your medical conditions? Very

A few times a month

Topical
Moderately

Does it reduce or eliminate the need for any medications? No

Minimal

Yes

Which medications and why? _________________________________________________________________________

Does cannabis use improve your quality of life? No

Yes

Do you experience any negative effects with cannabis? No

Yes

Explain: ____________________________

_______________________________________________________________________________________________________________________________________

ADDITIONAL INFORMATION: (Please provide any additional information that may be relevant to your examination today.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________

DECLARATION
I understand that the information I have been asked to provide is to help the health care professional to address
the condition(s) for which I am here today. I understand that if I have not accurately disclosed the requested
information, it may adversely impact the medical providers ability to make appropriate recommendations. I
certify that the information in this questionnaire is complete and accurate.

__________________________________________________________________________________________________
Patient Signature
Date

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The Hope Clinics

5267 University Way NE Seattle, WA 98105
Phone: (206) 466-1766
Fax: (206) 913-2815
info@thehopeclinics.com

Authorization to Release Medical Records

_______________________________________________________________________________________
Last Name
First Name
DOB
Male/ Female

Telephone

Email

Address

City, State, Zip

Name of Doctor

Name of Practice/Clinic

Telephone

Fax

Location

Date(s) of Care

Regarding the Above Condition

I hereby give specific authorization for the release of my medical records to The Hope Clinic for one year from the date signed
below. This release includes the transfer of my medical records by mail, facsimile, or any other electronic transmission method that
may be requested.
I understand that these records are confidential and may contain information regarding the diagnosis or treatment of HIV/AIDS,
sexually transmitted diseases, drug and/or alcohol abuse, mental illness or psychiatric treatment. I give specific authorization for
these records to be released for the purposes of continuing care.
I understand that this authorization is voluntary. I understand that my health information may be protected by the Federal Rules for
Privacy and/or state law. I understand that I may revoke this authorization at any time by notifying The Hope Clinic in writing.
I understand that my health information may be subject to re-disclosure. I specifically consent to the faxing of my medical records.
All faxed material will contain a confidentiality statement. However, I understand confidentiality at the receiving end cannot be
guaranteed.

I understand I have the rights to inspect or receive a copy of my protected health information, receive a copy of this authorization,
and refuse to sign this authorization.

Patient Signature: ___________________________________________________

206.466.1766

www.TheHopeClinics.com

Date:_____________________

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PATIENT INFORMED CONSENT

I am being evaluated for a health care professionals recommendation for medical cannabis. The medical care provider will
make this recommendation based, in part, on the medical information I have provided. I have not misrepresented my medical
condition in order to obtain this recommendation, and it is my intent to use cannabis only as needed for the treatment of my
medical condition, not for non-medical purposes.
Patient agrees by initialing the following:
_____

I must be a Washington resident to obtain a recommendation for the use of medical cannabis under RCW 69.51A.

_____

I am aware that I am paying for a medical examination and evaluation with the physician. The fee for the evaluation does not
guarantee that I will receive a recommendation. If I do not qualify for a recommendation I will still have to pay a $50 fee.

_____

The federal government has classified cannabis as a Schedule I controlled substance. Federal law prohibits the manufacture,
distribution, and possession of cannabis, including in states which provide for medical cannabis in their state laws.

_____

I understand that side effects may occur while I am taking medical cannabis. Side effects of medical cannabis can include but
are not limited to: increased heart rate, euphoria, dysphoria, confusion, low blood pressure, dizziness, inability to concentrate,
sedation, depression, restlessness, anxiety, paranoia, delusion, overeating, suppression of the bodys immune system,
impairment of shorter term memory, alterations in the perception of time and space, difficulty in completing complex tasks,
impairment of motor skills, reaction time and physical coordination. For some patients, chronic cannabis use can lead to
laryngitis, bronchitis and general apathy.

_____

I understand that some patients can become dependent on marijuana. This means they experience mild withdrawal symptoms
when they stop using marijuana. Signs of withdrawal symptoms, while generally mild, can include: feelings of depression,
sadness and irritability, restlessness or mild agitation, insomnia, loss of appetite, sleep disturbance, trouble concentrating, and
unusual tiredness.

_____

I understand the use of cannabis can affect coordination, motor skills and cognition, i.e., the ability to think, judge and
reason. While using cannabis, I should not drive, operate heavy machinery or engage in any activities that require me to be
alert and/or respond quickly. I understand that if I drive while under the influence of cannabis, I can be arrested for driving
under the influence.

_____

I understand that using cannabis while under the influence of alcohol or narcotics is not recommended. Additional side
effects may become present when using both alcohol and/or narcotics along with cannabis.

_____

I understand the benefits and risks associated with the use of cannabis are not fully understood and the use of cannabis may
involve risks that have not been identified.

_____

I certify that I have read this document and acknowledge that my manipulation, alteration or falsification of this form, or the
Hope Clinics medical cannabis recommendation, will result in the immediate termination of any legal right to my use of
medical cannabis. Furthermore, the Hope Clinics will report any of the above mentioned activities to the authorities.

_____

The health care provider, staff, and representatives of The Hope Clinics are addressing specific aspects of my medical care
and, unless otherwise stated, are in no way establishing themselves as my primary care physicians/provider. Furthermore, the
undersigned, my heirs, assigns, or anyone else acting on my behalf, hold the health care provider and his/her principals,
agents, and employees, free of and harmless from any responsibility for any harm resulting to me and/or other individuals as
a result of my medical cannabis use.

_____

I understand that the Hope Clinics are available to answer my questions about medical cannabis and the industry, and assist
me with any legal issues that arise based on my medical cannabis use. If the conversation or needed services exceeds 10
minutes I will need to schedule a consulting appointment where additional fees may be incurred based on the services
required. Legal consulting will be billed at $150/hour, and any other services, such as legal research and other inquiries, will
be billed at $50/hour.

I certify that I have read this document and understand its declarations.
__________________________________________________________________________________________________
Patient Signature

206.466.1766

Date

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The Hope Clinics

Privacy Information
This notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully. The Hope Clinics have implemented safeguards to protect your privacy. This
form gives a general overview of our privacy policy. Our full policy is available upon request.
In order to provide you with services, The Hope Clinics will receive personal information about your health, from you,
your physicians, and others who provide you with health care services with whom youve authorized to share that
information with us. This is also known as your Private Health Information (PHI) and is any information in our
possession that would allow someone to identify you and learn something about your health. It does not apply to
information that contains nothing that could reasonably be used to identify you.
We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all
administrative matters related to your care are handled appropriately. Patient files may be stored in open file racks and
will not contain any coding which identifies a patients condition or information which is not already a matter of public
record. The normal course of providing care means that such records may be left, at least temporarily, in administrative
areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff.
You agree to the normal procedures utilized within the office for the handling of patient records, PHI and other documents
or information.
2. We may send patients communications of appointment times, office changes, policies and products. We may do this by
telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you.
3. The Hope Clinics utilize a number of vendors in the conduct of business. These vendors may have access to PHI but
must agree to abide by our privacy policy.
4. You agree to bring any concerns or complaints regarding privacy to the attention of the Office Manager, Director of
Operations, or the health care professional.
5. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or
services.
6. We agree to provide patients with access to their records in accordance with state and federal laws.
7. You authorize the Hope Clinics to verify your status as a Hope Clinics patient to an access point for the purpose of
obtaining cannabis. This authorization is only valid for the period of time for which your recommendation is valid.
8. You authorize the Hope Clinics to disclose and verify your medical records to law enforcement should you be arrested
or detained related to your possession or use of cannabis. The Hope Clinics will only provide verification of your patient
status for the purpose of providing proof to justify your possession of cannabis. This authorization is only valid for the
period of time for which your recommendation is valid.
9. We may change, add, delete or modify any of these provisions to better serve the needs of both the office and the
patient. Patient will be informed accordingly.
10. You have the right to request restrictions in the use of your protected health information and to request change in
certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to
conform to your request.
ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE
Please sign the acknowledgment of receipt of this notice. Our intent is to make you aware of the possible uses and
disclosures of your protected health information and your privacy rights. If you decline to provide a signed
acknowledgment, you will not be able to do business with The Hope Clinics.

__________________________________________________________________________________________________
Patient Signature
Date

206.466.1766

www.TheHopeClinics.com

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