I understand that the information I have been asked to provide is for the diagnosis and treatment of the medical condition for which I am seeing the physician today, and that if I have not accurately and completely disclosed the requested information, it may adversely impact the physician’s ability to diagnose my condition and recommend appropriate treatment. I certify that the information in this questionnaire is accurate and complete.
By submitting this form, you acknowledge that you have been informed of and understand the following:
I am being evaluated for a physician’s recommendation for marijuana. The physician will make this determination based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non-medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of marijuana.
I must be a South Dakota resident to obtain an approval or recommendation for the use of cannabis (medical marijuana) under South Dakota state law.
Marijuana has not yet been approved by the Food and Drug Administration. Therefore, marijuana sold for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients (i.e., can vary in potency), impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.
The use of marijuana can affect coordination, motor skills, and cognition, i.e., the ability to think, judge, reason and act. While using marijuana, I should not drive, operate heavy machinery, or engage in any activities that require me to be alert and/or respond quickly. I understand that if I drive while under the influence of marijuana, I can be arrested for “driving under the influence.”
Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short-term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression, and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of marijuana may cause me to talk or eat in excess, alter my perception of time and space, and impair my judgment.
I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.
Smoking marijuana may cause respiratory problems and harm, including bronchitis, emphysema, and laryngitis. In the opinion of many researchers, marijuana smoke contains known carcinogens (chemicals that can cause cancer) and smoking marijuana may increase the risk of respiratory diseases and cancers in the lung, mouth, and tongue. In addition, marijuana smoke contains harmful chemicals known as tars. If I begin to experience respiratory problems when using marijuana, I will stop using it and report my symptoms to a physician. The physician will inform me of alternatives to smoking marijuana.
The risk, benefits, and drug interactions of marijuana are not fully understood. If I am taking medication or undergoing treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s).
Individuals may develop a tolerance to, and/or dependence on, marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should contact my personal physician. Signs of withdrawal can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances, and unusual tiredness.
Symptoms of marijuana overdose include, but are not limited to: nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms, or legs, anxiety attacks, and incapacitation. If I experience these symptoms, I should contact my primary care physician, or dial 911 or go to the nearest emergency room.
If DrRx Medical Marijuana Clinic subsequently learns that the information I have furnished is false or misleading, the recommendation for marijuana may be revoked. I agree to promptly meet with DrRx Medical Marijuana Clinic and/or provide additional information in the event of any inaccuracies or misstatements in the information I have provided.
***IMPORTANT***
Please note, IF the basis for your interest in Medical Marijuana is the relief of pain, we do require you to provide us details to substantiate the onset & location of your pain, when/where & who you had seen previously for the pain, proof of any tests done such as X-rays, CT Scan/MRI as well as information about any specific prior treatment you may have tried.
If you have any questions about this, please do not hesitate to call us directly at 605-799-3157