6/6/2019 Lotus Health LLC Follow Up/Progress Communication: Complete Upon Receipt

100% of survey complete.

The providers at Lotus Health LLC would like to know about your progress. Please answer all questions to the best of your ability. As always, feel free to email Teaera, Dr. Short, Dr. Goldenberg, or Dr. Pope directly with any questions you may have regarding your treatment plan. For dispensary information, please direct yourself to the Ohio Medical Marijuana Control Program website. You can also utilize Weedmaps.com or Leafly.com for a map of the dispensary locations.
HB523 indicates we must report non patient specific information pertaining to the health outcomes of our clients. Please make sure this form is filled out and sent back to us in the mail or electronically.

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* 1. Last Name

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* 2. First Name

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* 3. Age:

Under 18 Years

18-30 Years

31-50 Years

51-64 Years

65-80 Years

81-105 Years

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* 4. Do you have a registered caregiver?

Yes

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* 5. Please indicate the Ohio qualifying diagnosis you are attempting to treat with medical cannabis: (Only include the diagnosis in which you have actually been diagnosed by a certified medical professional legally able to diagnose). Please mark all that apply:

AIDS/HIV

Amyotrophic Lateral Sclerosis (ALS)

Alzheimer's Disease

Cancer

Chronic Traumatic Encephalopathy

Crohn’s disease

Epilepsy or another seizure disorder

Fibromyalgia

Glaucoma

Hepatitis C

Inflammatory Bowel Disease

Multiple Sclerosis

Pain that is either Chronic and Severe or Intractable

Parkinson’s Disease

Post-Traumatic Stress Disorder (PTSD)

Sickle Cell Anemia

Spinal Cord Disease or Injury

Tourette’s Syndrome

Traumatic Brain Injury

Ulcerative Colitis

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* 6. Please indicate if you have been able to utilize an Ohio Medical Marijuana Dispensary:

Yes

No, however I still have access to medication from other sources (private, protected)

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* 7. If you have not utilized and Ohio Dispensary, please indicate the reason:

Prices are too high

No open dispensary close enough to my home

The product I would like to use is not yet available

I have chosen not to utilize the medical marijuana program for medication

I am using the Ohio Dispensaries

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* 8. Have you been able to treat your ailment with any amount of success?

Yes

I have not yet obtained any medication

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* 9. Have you been able to decrease or stop any medications you were taking prior to starting medical cannabis to treat/prevent your ailment?

Yes, I have discontinued a previously prescribed medication

Yes, I have decreased a previously prescribed medication

No, I have not decreased nor discontinued any medications

I was not on any other medications for my ailment prior to utilizing cannabis

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* 10. If you have decreased or discontinued traditional medication, indicate the type(s) of medications.

Opiates (Oxycontin, Percocet, Vicodin, Morphine, etc.)

Benzodizepines (Xanax, Klonopin, Ambien, Ativan, Valium, etc.)

Anticonvulsants (Gabapentin, Tegretol, Keppra, Dilantin, Topamax, etc.)

Antidepressants/Antianxiety/Antipsychotic (Zoloft, Prozac, Wellbutrin, Celexa, Lexapro, Paxil, Effexor, etc.)

Over The Counter Medication (Ibuprofen, tylenol, aleve, aspirin, etc)

N/A

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* 11. Do you currently supplement with any cannabinoid products such as CBD oil?

Yes

I have tried and I did not see the benefit

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* 12. Do you feel as though cannabis has increased your overall quality of life?

Yes, Very Much

Yes, Somewhat

I have not yet been able to try medical cannabis

No, there has not been any type of improvement

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* 13. Have you communicated your current or planned cannabis use with your current healthcare providers?

Yes

Some, but not all of them

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* 14. If you have communicated your health plans with cannabis, what was the outcome?

Good, they are completely on board and/or they referred me to begin with

My provider is not on board, however does not plan to let me go as a patient

My provider was indifferent

Not Good, My provider stated I have to choose between cannabis medicine or not care and medication treatment with them

I have not communicated with any other provider about cannabis

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* 15. Which route(s) of administration do you use or plan to use once available?

Inhale (vape the flower)

Inhale (vape the cartridge oil processed with butane and/or ethanol)

Oral Tincture/Oil

Topical

Edibles

Patches/Lotions/Creams