Patient Registration — PremierMD NJ Medical Marijuana

1 Personal Information

First Name *

Last Name *

Date of Birth *

Gender *

Marital Status *

2 Contact Information

Street Address *

City *

State *

ZIP Code *

Phone *

Email *

3 Health Insurance

Coverage *

I have health insurance I am presently uninsured

Insurance Company e.g., Aetna, Cigna, Horizon NJ Health, Medicare, etc.

Member / Insurance ID

4 Reason for Visit

Select all services you may be interested in.

Medical Marijuana Evaluation Psychiatric Medication Management General Medical Visit Therapeutic Counseling Routine Physical / Well-Check Acupuncture Ketamine-Based Antidepressant Treatment Learn more ↗

Key Healthcare Issue Critical to You Please share the primary reason you're seeking medical care. (e.g., "Neck pain for 5 yrs, getting worse, can't sleep now.")

Your Other Doctors If you would like us to communicate with your other care providers, please list their name, specialty, and location. (e.g., Joe Smith, FP, Hillsborough)

5 Medical History

Current Medication List Prescribed medicines and supplements — include dose and frequency if possible. (e.g., Crestor 10 mg, 1/day)

Allergy History e.g., Penicillin/rash, peanuts/anaphylaxis. Leave blank if none.

Past Medical History Conditions you've been diagnosed with. (e.g., Hypertension since 2015, stable)

Surgical History Any surgeries, when they took place, and what they were for. (e.g., Appendicitis — 2003)

6 Family History

Family Medical History A few words about the health of your family members. (e.g., Mom, 65, alive and well, has high BP)

Family Cancer History Any history of cancer in your family. (e.g., GF, pancreatic cancer age 53; M — Breast Cancer, 39)

7 Pharmacy Preferences

Local Pharmacy If you would like us to send prescriptions to a local pharmacy, include the name and location. (e.g., Rite Aid on Rehill St. in Somerville)

Mail Order Pharmacy If you prefer mail order, include the pharmacy name. (e.g., OptumRX, or CVS Caremark)

8 Lifestyle

Work Status Your current occupation, or previous job if retired or disabled. Helps identify health risks like chemical exposure or repetitive strain.

Recent Travel History (past 1 year) Helps screen for conditions more common in certain regions.

Tobacco Use *

Presently smoke Used to, quit some time ago Don't use it, never have

Exercise Frequency

Never Once a week A few times a week Every day

Recreational Substance Use Helps us understand health risk factors such as hepatitis risk and addiction. Leave blank if none. (e.g., Current — MJ smoke 2–3x/wk)

Weekly Alcohol Consumption Please share how much alcohol you consume regularly in a given week. (e.g., 2 glasses wine, 3–4x/wk)

Preventative Screening Which of these preventative screening procedures have you ever had?

Pap smear Mammogram Colonoscopy Cologuard Genetic Cancer Screening Bone Density Test

9 Mental Health Screening

Over the last 2 weeks, how often have you been bothered by the following?

Having little interest or pleasure in doing things *

Not at all Several days More than half the days Nearly every day

Feeling down, depressed, or hopeless *

Not at all Several days More than half the days Nearly every day

10 Sexual Health

Sexual health is an important aspect of general health. These questions help us provide complete care.

Are you sexually active?

Not sexually active Active — with women Active — with men Active — with both

How many sexual partners have you had in the last year?

Are there any sexual problems you'd like us to address? *

Yes No

11 Mental Health Background

These questions help our clinical team understand your psychiatric history before your visit.

Psychiatric Diagnoses Have you been given any psychiatric diagnoses? If yes, please list below.

Depression History How long have you had depression and what treatments have you had for it? (e.g., "Diagnosed in my 20's, on medications on and off for the last 15 years")

Previous Medications Have you ever been prescribed any medications for your psychiatric condition(s)? Please list any such medications you've been prescribed in the past but are NOT taking now.

Previous Anti-Depressant Therapy What medications for depression have you been on before?

Current Anti-Depressant Therapy What medications for depression are you on now? Can answer "None".

Current Goals & Concerns From a mental health perspective, what are your current concerns and goals?

Your Other Providers Please let us know the other providers (psychiatrists, therapists, internists, etc.) you've seen, or are seeing now, for your current problem.

Family Mental Health History Any history of mental illness in your family. (e.g., Mother — depression, Father — Bipolar)

12 Additional Information

Anything else you'd like our clinical team to know?

13 Consent & Signature

Electronic Signature * Per the ESIGN Act of 2000, your typed name below is as legally binding as a handwritten signature. It affirms the accuracy of the information submitted above and your consent to the practice policies referenced above.

14 How Did You Find Our Practice?

Select all that apply. *

Google Search Insurance Website Patient Referral Provider / Doctor Referral Other