COPING WITH CANCER CANNABIS INTAKE FORM COPING WITH CANCER CANNABIS INTAKE FORM Date MM slash DD slash YYYY MCA #:(if you have it)Patient Name First Last Date of Birth: MM slash DD slash YYYY Age:Patient Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PATIENT COUNTY:CELL PHONE NUMBER:HOME PHONE NUMBER:WORK PHONE NUMBEREMAIL ADDRESS:RACEAfrican AmericanCaucasianHispanicAsianNative AmericanOtherGenderMaleFemaleThird ChoiceType of Cancer:Date of Diagnosis: MM slash DD slash YYYY Where did you hear about this program?Treatment Center:Referring person(Social worker, Patient Care Navigator, Doctor)MEDICAL HISTORYSymptoms & Treatment Side Effects (Check all that apply) Nausea Loss of Appetite Weight Loss Weight Gain Neuropathy Sleep Trouble Fatigue Weakness Memory Trouble Anxiety Depression Pain If Pain was checked please describeList any other symptoms and treatment side effectsWhat types of examinations have you had (Check all that apply) Bloodwork CAT scan MRI X-Ray PET Scan Other (please describe) If checked other examinations please describeWhat treatments have you had (Check all that apply) Surgery Chemotherapy Radiation Immunotherapy Prescription Medication Other (please describe) If checked other treatments please describePlease list your current medications, supplements & herbs (or attach a sheet with the informationFileMax. file size: 16 MB.Please list any allergies (medications, food or environmental & your reaction)Please list any other major health problems, hospitalizations and surgeries that you have had and whenFAMILY MEDICAL HISTORYPlease check any of the following family members that have had cancer Mother Father Brother Sister What type of cancer did your family member(s) have?LIFESTYLE AND SOCIAL LIFEHow many glasses of water do you drink per day?How many alchoholic beverages do you drink per week?Tobacco (how much and how long)Are you able to excercise? If so how much & what kind per week)How many hours of sleep do you ger per night?Do you feel rested in the morning?With whom do you live?Are you?EmployedUnemployedDisabledOtherWhat do you do for work?What are your health goals?CANNABIS HISTORYAre you currently using Cannabis?YesNo (if no, you've completed the form)Third ChoiceHow are you using Cannabis (Check all that apply) Vape Pens Smoke Flower Tinctures Edibles Tablets Topicals Concentrates Other (please describe) If you use other forms of Cannabis please describeHow much and how often do you use Cannabis? (Dosing and frequency)How does Cannabis help you?Have you had any negative effects from Cannabis? If yes, please describe)ANY ADDITIONAL NOTESAny consult provided by the Zaching Against Cancer Foundation is based on cancer patient feedback and staff training and is not intended to be medical advice. The ZACF is not responsible for any adverse effects from cannabis. There is a trial and error period for every patient new to cannabis. The consult is intended to provide guidelines during this period. On behalf of the patients who have obtained their patient number from the Maryland Cannabis Administration, this intake form will be forwarded to Cannabis Physicians. Once a number has been obtained from the state it must be activated by a certified cannabis physician. We are in partnership with Cannabis Physicians and can provide this service for free.
