As it appears on your ID card

Please enter your SSN, no hyphens or spaces (i.e. 123456789). If you are not comfortable entering this online, we understand and can do it at the office but please note it will add 10+ minutes to your visit. If you don't want to share this online just enter all 0's.

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

What type(s) of condition(s) do you think you'd like to be seen for?

Have you had any adverse reactions to smokable products?

Please type as many your chronic medical conditions as you can. Please separate them with a comma.

Please note any hospitalizations including reason for hospitalization and year hospitalized.

Please type all the medications you are taking along with the reason you are taking them. Please separate each medication with a comma.

There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancers, including glioma. There is evidence to suggest that cannabinoids (and the endocannabinoid system more generally) may play a role in the cancer regulation processes. Due to a lack of recent, high quality reviews, a research gap exists concerning the effectiveness of cannabis or cannabinoids in treating cancer in general.

There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for epilepsy. Recent systematic reviews were unable to identify any randomized controlled trials evaluating the efficacy of cannbinoids for the treatment of epilepsy. Currently available clinical data therefore consist solely of uncontrolled case series, which do not provide high quality evidence of efficacy. Randomized trials of efficacy of cannabidiol for different forms of epilepsy have been completed and await publication.

There is limited evidence that cannabinoids are an ineffective treatment for improving intraocular pressure associated with glaucoma. Lower intraocular pressure is a key target for glaucoma treatments. Nonrandomized studies in healthy volunteers and glaucoma patients have shown short-term reductions in intraocular pressure with oral, topical eye drops, and intravenous cannabinoids, suggesting the potentail for therapeautic benefit. A good-quality systemic review identified a single small trial that found no effect of two cannabinoids, given as an oromucosal spray, on intraocular pressure. The quality of evidence for the finding of no effect is limited. However, to be effective, treatments targeting lower intraocular pressure must provide continual rather than transient reductions in intraocular pressure. To date, those studies showing positive effects have shown only short-term benefit on intraocular pressure (hours), suggesting a limited potential for cannabinoids in the treatment of glaucoma.

There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS. There does not appear to be good-quality primary literature that reported on cannabis or cannbinoids as effective treatments for AIDS wasting syndrome.

There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS. There does not appear to be good-quality primary literature that reported on cannabis or cannbinoids as effective treatments for AIDS wasting syndrome.

There is limited evidence (a single, small fair-quality trial) that nabilone is effective for improving symptoms of posttraumatic stress disorder. A single, small crossover trial suggestes potential benefit from the pharmaceutical cannabinoid nabilone. This limited evidence is most applicable to male veterans and contrasts with non-randomized studies showing limited evidence of a statistical association between cannabis use (plant derived forms) and increased severity of posttraumatic stress disorder symptoms among individuals with posttraumatic stress disorder. There are other trials that are in the process of being conducted and if successfully completed, they will add substantially to the knowledge base.

There is insufficient evidence that cannabinoids are an effective treatment for symptoms associated with amyotrophic lateral sclerosis. Two small studies investigated the effect of dronabinal on symptoms associated with ALS. Although there were no differences from placebo in either trial, the sample sizes were small, the duration of the studies was short, and the dose of dronabinol may have been too small to ascertain any activity. The effect of cannabis was not investigated.

There is insufficient evidence to support or refute the conclusion that dronabinol is an effective treatment for symptoms associated with Crohn's.

There is insufficient evidence that cannabinoids are an effective treatment for the motor system symptoms associated with Parkinson's disease or pain induced dyskinesia. Evidence suggests that the endocannabinoid system plays a meaningful role in certain neaurodegenerative processes; thus, it may be useful to determine the efficacy of cannabinoids in treating the symptoms of neurodegenrative diseases. Small trials of oral cannabinoid preperations have demonstrated no benefit compared to a placebo in ameliorating the side effects of Parkinson's diease. A seven-patient trail of nabilone suggested that is improved the dyskinesia associated with levodopa therapy, but the sample size limits the interpretation of the data. An observational study demonstrated improved outcomes, but the lack of a control group and the small sample size are limitations.

There is substantial evidence that oral cannabinoids are an effective treatment for improving patient reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on clinician measured spasticity. Based on evidence from randomized controlled trials included in systematic reviews, an oral cannabis extra, nabiximols, and orally administered THC are probably effective for reducing patient reported spasticity scores in patients with MS. The effect appears to be modest. These agents have not consistently demonstrated a benefit on clinician meausred spasticity indices.

There is substantial evidence that cannabis is an effective treatment for chronic pain in adults. The majority of studies on pain evaluated nabiximols outside the United States. Only a handful of studies have evaluated the use of cannabis in the United States. and all of them evaluated cannabis in flower form provided by the National Institute on Drug Abuse. In contrast, many of the cannabis products that are sold in state-regulated markets bear little resemblance to the products that are available for research at the federal level in the United States. Pain patients also use topical forms. While the use of cannabis for the treatment of pain is supported by well controlled clinical trials, very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Please check all that apply.

Anything else you would like to add?