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What is MMJ?
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Medical Cannabis Connection
Home
What is MMJ?
Mission
Updates and Information
About Us
Contact
MCCONY Merchandise
Service Advertisements
Patient information
Date of consultation
Date of consultation
MM
DD
YYYY
Name
*
Name
First Name
Last Name
Email Address
*
What is your zipcode?
Phone number where you can be reached
Phone number where you can be reached
Country
(###)
###
####
DOB of patient
*
DOB of patient
MM
DD
YYYY
Height in inches
Weight in pounds
Allergies
*
Provider Information
Primary physician
*
Physician recommending mmj
*
Indication in which mmj is being used:
*
Cancer
HIV/AIDS
ALS
Parkinson's Disease
Multiple Sclerosis
Damage to the spinal cord with spasticity
Epilepsy
Inflammatory bowel disease
Neuropathies
Huntington's Disease
Chronic pain
Date of certification
Date of certification
Ask if they have the recommendation and document for reminder purpose
MM
DD
YYYY
Dispensary Information
NYS Dispensary
Where does the patient go to get the NYS MMJ
Bloomfield Industries
Columbia Care
Etain
Pharmacann
Vireo Health
Which location do you go to?
Bloomfield: 1304 Buckley Road, Syracuse, NY 132152
Bloomfield: South Union Road, Williamsville, NY 14221
Bloomfield: 2001 Marcus Ave., Lake Success, NY 11042
Columbia Care: 212 East 14th St, NY, NY 10003
Columbia Care:345 Cornelia St, Plattsburgh, NY 12901
Columbia Care:200 West Ridge Rd., Rochester, NY 14615
Columbia Care: 1333 E. Main St., Riverhead, NY 11901
Etain: 402 North Pearl Street, Albany, NY 12207
Etain 445 State Route 28, Kingston, NY 12401
Etain: 2140 Erie Boulevard, East Syracuse, NY 13224
Etain: 55 Main St., 2nd Floor, Yonkers, NY 10701
Pharmacann:25 Northpointe Parkway, Amherst, NY 14228
Pharmacann: 642 Old Liverpool Road, Liverpool, NY 13088
Pharmacann: 10 Executive Park Drive, Albany, NY 12203
Pharmacann: 405 Hunts Point Avenue, Bronx, NY 10474
Vireo: 221-223 E. Post Road, White Plains, NY 10601
Vireo: 89-55 Queens Blvd, Elmhurst, NY 11373
Vireo: 589 Harry L Drive, Johnson City, NY 13790
Vireo: 38 Fuller Road, Albany, NY 12205
Round trip travel time (in hours)
please note approximate travel time in hours (1/2 hour= 0.5)
Industrial Hemp
if not taking a NYS product, what product does the patient take? (eg, CW, HH, PH)
What is the ratio of THC: CBD
*
Document as THC : CBD
Ratio per volume
*
THC ratio in mg
*
document the ratio of THC in MG (from ratio above)
CBD ratio in MG
*
document the ratio of CBD in MG (from ratio above)
Dosing Information
Enter information that the patient tells you. Be careful about how reported (mg vs mL and THC vs CBD).
What is the dose of THC / DOSE (mg)
enter the mg dose of THC for EACH dose
What is the dose of THC / DOSE (mL)
enter the mL dose of THC for EACH dose
What is the dose of CBD / DOSE (mg)
enter the mg dose of CBD for EACH dose
What is the dose of CBD / DOSE (mL)
enter the mL dose of CBD for EACH dose
How many times a day is the dose given?
*
Choose if dose is the same each administration
1
2
3
4
5
6
If dose not the same write dose below
Make sure notation is in MG or ML
Patient History
What other AED's taken? (select all that apply)
Acetazolamide (Diamox®)
Carbamazepine (Tegretol®)
Clobazam (Onfi®)
Clonazepam (Klonopin®)
Divalproex (Depakote® tabs)
Eslicarbazepine acetate (Aptiom®)
Ethosuximide (Zarontin®)
Felbamate (Felbatol®)
Gabapentin (Neurontin®)
Lacosamide (Vimpat®)
Lamotrigine (Lamictal®)
Levetiracetam (Keppra®)
Nitrazepam (Mogadon®)
Oxcarbazepine (Trileptal®)
Perampanel (Fycompa®)
Piracetam (several brand names)
Phenobarbital
Phenytoin (Dilantin®)
Pregabalin (Lyrica®)
Primidone (Mysoline®)
Rufinamide (Banzel®)
Sodium valproate (Depakene® liquid)
Stiripentol (Diacomit®)
Tiagabine (Gabitril®)
Topiramate (Topamax®)
Vigabatrin (Sabril®)
Zonisamide (Zonagran®)
List other medications:
Will build a database of other medications when reported
Patient reported outcomes
Do you feel adding MMJ has improved quality of life
Yes
No
Describe how quality improved
List improvements
Reduction of other medications since mmj
*
Yes
No
What medications have been reduced or eliminated
Document medications eliminated or medication reduced
Thank you!