Online Evaluation Order Number First Name * Last Name * Date of Birth * Gender * Female Male Mobile Number * Email Address * Address * City * State * Zip Code * Do you suffer from any of the following? Please check the conditions for which you seek for medical marijuana. * Chronic pain Opioid replacement Cancer Post-traumatic stress disorder (PTSD) Neuropathy Epilepsy HIV/AIDS Spinal cord injury Inflammatory bowel disease Parkinson’s disease Amyotrophic lateral sclerosis (ALS) Multiple sclerosis Huntington’s disease Other Are you taking any other medications? * YesNo Have you ever been diagnosed with schizophrenia? * YesNo Have you ever experienced hallucinations before? * YesNo Do you smoke cigarettes? * YesNo Do you drink alcohol? * YesNo Are you pregnant? * YesNo Are you currently nursing a child? * YesNo Please share any medical records with us pertaining to your medical condition. Please limit TOTAL ATTACHMENT SIZE submitted (including ID below) to under 25MB. File formats allowed: pdf, doc, odt, jpg, jpeg, png, and gif. Add Files Please enter any additional medical information that you want to share with us. Upload a clear picture of a government-issued ID (preferably DMV-issued NY State ID such as driver license, learner permit, or non-driver ID, but other state IDs, passports, etc. are also acceptable). File formats allowed: jpg, jpeg, png, pdf, and gif. Add Files I have reviewed my information and understand any mistakes could lead to delays in receiving my recommendation. * Yes Terms and Conditions (https://www.cannabismd.nyc/terms-and-conditions/) * I have read the legal terms above and agree to use Telemedicine as communication means with doctor and have been informed about the risk of cannabis use.