All MMTC Florida clinics are now accepting regular appointments.

In certain areas affected by Hurricane Ian, telehealth visits may be an option for follow-up visits.

Medical Marijuana Treatment Clinics of Florida Health History Questionnaire

Name(Required)
MM slash DD slash YYYY
Address(Required)
If not applicable, please put "Not Applicable" or "N/A"
Have you been diagnosed with any type of mental illness?
If not applicable, please put "Not Applicable" or "N/A"
If not applicable, please put "Not Applicable" or "N/A"
Military service?(Required)
Did service include combat?(Required)
History of smoking or tobacco use?(Required)
History of Alcohol use?(Required)
Do you have any medical problems? Click all that apply(Required)
Year
Type of Surgery
Please list dose and frequency of any medications you are currently taking. If not applicable, please put "Not Applicable" or "N/A":
List medication allergies, if any. If not applicable, please put "Not Applicable" or "N/A":
Are you allergic to latex?(Required)
Allergic to iodine or shellfish?(Required)
Do you have biological family members who have major medical issues, or who have been diagnosed with depressive or anxiety disorders?(Required)
Are you currently under the care of a mental health provider (i.e., psychiatrist, psychologist, counselor)?
General(Required)
Skin / Hematologic(Required)
HEAD, NECK, EARS, EYES, THROAT(Required)
RESPIRATORY(Required)
CARDIAC(Required)
GASTROINTESTINAL(Required)
Any history of severe nausea with anesthesia?(Required)
URINARY(Required)
FOR MEN
FOR WOMEN
Peripheral Vascular/Musculoskeletal
Can you walk a mile?(Required)
NEUROLOGIC/PSYCHOLOGICAL(Required)
ENDOCRINE(Required)
MM slash DD slash YYYY

This website is intended for informational use only. It is not meant to consitute medical advice. Please contact yout health provider prior to making any medical decisions.