Add New Case ArfinnMed

Patient Information

A case for this patient already exists! Click here for updated patient files.

Office Visited

Acquisition Source

eg. Physician Referral, Marketing Channel, Event, etc.

Patient Registry Number

Launch Florida OMMU

Launch PADOHMMP

Qualifying Condition*

Cancer Type

Identify Terminal Illness

Identify Pain Type

Describe Qualifying Condition

Select Symptoms

Secondary Qualifying Condition (optional)

Use as EMR?

No
Yes

EMR Use

Patient Name

(PHI is encrypted and HIPAA compliant. Only you will have access to this information.)

Patient Email

(PHI is encrypted and HIPAA compliant. Only you will have access to this information.)

Patient D.O.B.

(PHI is encrypted and HIPAA compliant. Only you will have access to this information.)

Patient Phone

(PHI is encrypted and HIPAA compliant. Only you will have access to this information.)

Allow SMS Updates*

Allow patient to update their efficacy via text message.

Patient Height (Feet)

Patient Height (Inches)

Patient Weight (lbs)

Patient BMI

History of Present Illness

History Notes Template

– Fill Out Other Fields –

Physical Exam Notes

Physical Exam Template

– Fill Out Other Fields –

Medical and Surgical History

Medical History Template

– Fill Out Other Fields –

Symptom Keywords

Please list symptoms associated with this patient, separated by comas.

Is the patient pregnant?

Yes
No

PMP Confirmation

Yes
No

Allergies

Medication and/or additional Supplements and Vitamins

This field will be viewable by other members.

Possible Interactions

Patient Age Range*

Patient Sex*

Patient Gender

Specify Gender

Treatment & Efficacy

Treatment Recommended*

Treatment Recommended (Other)*

Cannabis Profile*

Cannabis Profile (Other)*

Cannabis Profile Ratio

THC to CBD Ratio (##:##)*

Primary Delivery Mode*

Delivery Mode (Other)*

Amount per Dose

Amount per Dose (Other)

Daily Dosage*

Daily Dosage (in MG)*

Dosing Instructions

The patient will be able to view these instructions in their Patient Portal.

Would you like to add alternate delivery modes?

Yes
No

Alternate Delivery Mode 1

Cannabis Profile

Cannabis Profile (Other)*

Cannabis Profile Ratio

THC to CBD Ratio (##:##)*

Alternate Delivery Mode 1

Alternate Delivery Mode 1 (Other)*

Amount per Dose

Amount per Dose (Other)

Daily Dosage

Daily Dosage (in MG)*

Alternate Delivery Mode 2

Cannabis Profile

Cannabis Profile (Other)*

Cannabis Profile Ratio

THC to CBD Ratio (##:##)*

Alternate Delivery Mode 2

Alternate Delivery Mode 2 (Other)*

Amount per Dose

Amount per Dose (Other)

Daily Dosage

Daily Dosage (in MG)*

Alternate Delivery Mode 3

Cannabis Profile

Cannabis Profile (Other)*

Cannabis Profile Ratio

THC to CBD Ratio (##:##)*

Alternate Delivery Mode 3

Alternate Delivery Mode 3 (Other)*

Amount per Dose

Amount per Dose (Other)

Daily Dosage

Daily Dosage (in MG)*

Additional Cannabinoids Present

Additional Cannabinoids Present (Other)*

Dominant Terpene Content

Dominant Terpene Content (Other)*

Efficacy*

Please Describe Adverse Reaction*

General time period to achieve results stated above

State*

State (Other)*

Dispensary Used

Dispensary Used (Other)*

Medical Cannabis Name

Medical Cannabis Name (Other)

Notes

Notes Template

– Fill Out Other Fields –

Referral / Certification Name

Patient Access Code

Name

This field is for validation purposes and should be left unchanged.

Patient Case Details

Patient Information

EMR Use

Treatment & Efficacy

Alternate Delivery Mode 1

Alternate Delivery Mode 2

Alternate Delivery Mode 3