Metro Direct Care Medical Patient Portal

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1. Patient Demographics 2. Patient Insurance Information 3. Health History 4.Medicinal Marijuana Screening Questionaire

4.Medicinal Marijuana Screening Questionaire

All information contained in this questionnaire is strictly confidential and will become part of your medical record. If you do not fill in fields with an asterisk the form will not submit. Please call 202-368-6820 if you need assistance. If you have not received a call back in 7 days,we apologize . Please give us call and you will be given priority!

First Name *

Last Name *

Address *

Please enter your street address including zip-code<br/>

Date of Birth

Are you a full time DC resident? *

Yes

Phone Number *

Email Address

Qualifying medical condition:

HIV

AIDS

Cancer

Chemotherapy

Radiotherapy

Glaucoma

Conditions characterized by severe and persistent muscle spasms, such as multiple sclerosis

Use of azidothymidine or protease inhibitors

Decompensated Cirrhosis

Amyotrophic lateral Sclerosis (Lou Gehrig's Disease)

Hospice Patients with less than 6 months to live

Cachexia or wasting syndrome

Alzheimer's Disease

Seizure disorders

Please check all that apply:<br/>Do not check a box unless you have been diagnosed with the condition and have a hard copy of the diagnosis from your doctor or proof of medications used for treatment of the condition.

OR

Qualifying medical treatment:

Chemotherapy

Use of azidothymidine or protease inhibitors

Radiotherapy

Please check all that apply

IF you do not have a qualifying condition or treatment, please describe why you feel you may benefit from medicinal marijuana

Do you have medical documentation of your qualifying condition? *

Yes

Is your primary care physician aware of your desire to use marijuana as an optional medical treatment? *

Yes

May we discuss your desire with your primary care physician? *

Yes

Name of physician and telephone number

Best day and time to contact you? *

How did you find out about us?

* Required field