Route Assessment Patient Full Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Are you interested in smokeable flower?(Required) Yes No Do you have a history of substance use disorder?(Required) Yes No CommentsIs there a family history of substance use disorder?(Required) Yes No CommentsHave you tried any products purchased from a Florida Licensed Dispensary?(Required) Yes No If Yes, Which of the following routes below have you tried?Edibles?(Required) Yes No Start Date MM slash DD slash YYYY *Use Estimated Start Date if Unknown*End Date(Required) MM slash DD slash YYYY *Put Today's Date If Still Using*How Much Improvement?(Required) Significant Improvement Moderate Improvement Minimal Improvement No Improvement Financial Cost of effective dose in this form is prohibitive CommentsInhalation/Vape?(Required) Yes No Start Date MM slash DD slash YYYY *Use Estimated Start Date if Unknown*End Date(Required) MM slash DD slash YYYY *Put Today's Date If Still Using*How Much Improvement?(Required) Significant Improvement Moderate Improvement Minimal Improvement No Improvement Financial Cost of effective dose in this form is prohibitive CommentsOral?(Required) Yes No Start Date MM slash DD slash YYYY *Use Estimated Start Date if Unknown*End Date(Required) MM slash DD slash YYYY *Put Today's Date If Still Using*How Much Improvement?(Required) Significant Improvement Moderate Improvement Minimal Improvement No Improvement Financial Cost of effective dose in this form is prohibitive CommentsSublingual?(Required) Yes No Start Date MM slash DD slash YYYY *Use Estimated Start Date if Unknown*End Date(Required) MM slash DD slash YYYY *Put Today's Date If Still Using*How Much Improvement?(Required) Significant Improvement Moderate Improvement Minimal Improvement No Improvement Financial Cost of effective dose in this form is prohibitive CommentsSuppository?(Required) Yes No Start Date MM slash DD slash YYYY *Use Estimated Start Date if Unknown*End Date(Required) MM slash DD slash YYYY *Put Today's Date If Still Using*How Much Improvement?(Required) Significant Improvement Moderate Improvement Minimal Improvement No Improvement Financial Cost of effective dose in this form is prohibitive CommentsTopical?(Required) Yes No Start Date MM slash DD slash YYYY *Use Estimated Start Date if Unknown*End Date(Required) MM slash DD slash YYYY *Put Today's Date If Still Using*How Much Improvement?(Required) Significant Improvement Moderate Improvement Minimal Improvement No Improvement Financial Cost of effective dose in this form is prohibitive Comments
