Patient information
Date of consultation
Date of consultation
Name *
Name
Phone number where you can be reached
Phone number where you can be reached
DOB of patient *
DOB of patient
Provider Information
Indication in which mmj is being used: *
Date of certification
Date of certification
Ask if they have the recommendation and document for reminder purpose
Dispensary Information
NYS Dispensary
Where does the patient go to get the NYS MMJ
please note approximate travel time in hours (1/2 hour= 0.5)
if not taking a NYS product, what product does the patient take? (eg, CW, HH, PH)
Document as THC : CBD
document the ratio of THC in MG (from ratio above)
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).
enter the mg dose of THC for EACH dose
enter the mL dose of THC for EACH dose
enter the mg dose of CBD for EACH dose
enter the mL dose of CBD for EACH dose
Choose if dose is the same each administration
Make sure notation is in MG or ML
Patient History
What other AED's taken? (select all that apply)
Will build a database of other medications when reported
Patient reported outcomes
List improvements
Document medications eliminated or medication reduced