Forms and Policies
Patient Oriented
Intake for Patients and Caregivers
Intake for Patients: Long form
Side Effects Checklist and Log
Patient Testimonial, Video, Photo, Audio Release Consent
This 19-item assessment helps the patient identify areas in his or her life negatively affected by marijuana use, including social relationships, self-esteem, work/finances, motivation, physical health, memory, and legal problems.
Talking to Your Health Care Provider
Excerpts from the book Medical Marijuana 101 by Mickey Martin, Ed Rosenthal, and Gregory T. Carter, M.D., with an emphasis on information patients can bring to their providers when interested in talking about medicinal cannabis use.
Medicinal Cannabis and Chronic Pain: Information for Patients
Developed as part of this project, this brochure is intended to educate patients considering the use of medicinal cannabis about risks, routes of administration, and safe use.
Journal for patients to use when beginning treatment to record dose, frequency of use, pain levels, and functionality. From Healthy Whole Solutions.
A sample agreement, modified from an opioid treatment agreement, for use when establishing a treatment plan and guidelines with your patient.
Documentation of health care professional’s authorization to engage in the medical use of marijuana in Washington State (as required by RCW 69.51A.010(5). Must be printed on tamper-resistant paper.
Patient Resources Americans for Safe Access
https://www.safeaccessnow.org/resources_for_patients
Provider Oriented
Initiating a Cannabis informed practice
Patient Focused Checklist Provider
Informed Consent – Release of Liability Statement
Initial Medical Assessment of the Patient Asking about Medical Cannabis
Evernote: Canadian Consortium for the Investigation of Cannabinoids (CCiC)
Evernote (CCIC)
Evernote (CCIC)
This tree can be used to determine whether medicinal cannabis is appropriate for your patient and assist in the development of a treatment plan. Adapted from Grant et al, 2012.
This intake checklist provides a simple outline for patient assessment, cannabinoid initiation, treatment objectives, and follow-up.
Canadian Consortium for the Investigation of Cannabinoids
This tool can be used to track improvements in pain-related symptoms over the treatment period.
Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) —
This 8-item tool, developed by the World Health Organization (WHO), screens patients for substance use and related problems.
Behavioral Assessment
Assess risk for dependence and related behavioral issues
Clinical Tools (From UW and CCIC)