Medical Cannabis Telehealth
Visit: [checkbox value="Telehealth. |Office Visit. |Telephone"] [textarea] CC: [checkbox value="pain |nausea |cancer |seizures |glaucoma |crohn's |PTSD |hepatitis C |HIV |AIDS |muscle spasms |cachexia |agitation of Alzheimer's |ALS"] Condition Associated: [checkbox value="Cachexia/Wasting syndrome |PTSD |Severe or chronic pain |Severe nausea |Severe or persistent muscle spasm |Seizures"] HPI: Patient presents for [checkbox value="an initial MMJ certification. |a MMJ certification renewal. |a MMJ consultation. "] [textarea] SH: Alcohol: [checkbox value="none |rarely |occasionally |regularly "] [text] Tobacco: [checkbox value="none |cigarettes |pipes |vape |chew/dip "] [text] Work: [checkbox value="none |retired |disabled |full time |part time |student |stay-at-home parent"] [text] GENERAL APPEARANCE [textarea default="Alert. No distress. Well-nourished and developed."] GAIT [textarea default="Normal base, balance, stride mechanics, and turns."] ROS: Attached Assessment: [checkbox value=" Patient Qualify for Medical Cannabis Program NYS 12 months |Patient Qualify for 3 month MCP NYS |Patient does not qualify"] [text] Plan: [checkbox value=" Patient to have 3 month follow up after beginning Cannabis Medicine |Patient to inform all providers of use of cannabis medicine. |Patient to sign the Cannabis use agreement"] [text]
There are 18 form elements.