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Complete this medical marijuana form before your medical examination.

 

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                 Email:

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I want my certificate:

 Emailed to me     Faxed to me    Mailed via the U.S. Post Office
 

Street Address:

  Colo. License #:
 

City:

 State: Zip:
 

Phone:

              Fax:

Please review this list of qualifying medical conditions as outlined below, select your condition (s), and email this form to the Colorado Medical Marijuana Associates Physicians.

 

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1.  Acquired hypothyroidsm 

2.   Acute Gastritis

3.  Acute Sinusitis

4.  ADD other

5.  ADD w hyperactivity

6.  ADD w/o hyperactivity

7.  Adrenal Cortical Cancer 

8.  Agoraphobia

9.  AIDS Related Illness

10.  Alcohol Abuse

11.  Alcoholism

12.  Alopecia

13.  Amphetamine Depend

14.  Amyloidosis

15.  Amytrophic Lateral Sclero 

16.  Anaphylactic or Reaction

17.   Angina pectoris

18.     Ankylosis

19.     Anorexia

20.     Anorexia Nervosa

21.     Anxiety Disorder

22.     Arteriosclerotic Heart Dis X

23.     Arthritis, Degenerative

24.     Arthritis, post traumatic 

25.     Arthritis, Rheumatoid

26.     Arthropathy, gout

27.     Asthma, unspecified

28.     Atrophy Blanche

29.     Autism/Aspergers

30.     Autoimmune disease

31.     be a specious disease

32.     Behcet’s Syndrome

33.     Bell’s palsy

34.     Bipolar Disorder

35.     Brain malignant tumor

36.     Brain Trauma

37.     Breast Cancer

38.     Bruxism

39.     Bulemia A

40.     Bulemia

41.     Cachexia

42.     Cancer, site unspecified 

43.     Cardiac conduction disord X

44.     Carpal Tunnel Syndrome 

45.     Celiac disease

46.     Cerebellar Ataxia

47.     Cerebral Aneurism

48.     Cerebral Palsy

49.     Cervical Disk Disease

50.     Cervicobrachial Syndrome 

51.     Charcot-Marie-Tooth

52.     Chemotherapy Convales V

53.     Chronic Fatigue Synd

54.     Chronic Obst Pulmo Dis 

55.     Chronic Sinusitis

56.     Club foot

57.     Cluster Headaches

58.     Coat’s Syndrome

59.     Cocaine Dependence

60.     Colitis

61.     Colitis, Ulcerative

62.     Colon diverticulitis

63.     Color Blindness

64.     Compression of Brain

65.     Congestive Heart Failure 

66.     Conjuctivitis

67.     Constipation

68.     Cough

69.     Cystic Fibrosis

70.     Darier’s Disease

71.     Delerium Tremens

72.     Dentofacial anomaly pain 

73.     Dermatomyositis

74.     Diabetes Adult Ons Unctrl 

75.     Diabetes Adult Onset

76.     Diabetes Insulin Depend

77.     Diabetes Type I Ctrld 

78.     Diabetes Type I, Unco 

79.     Diabetic Neurpathy

80.     Diabetic Ophthalmic Dis 

81.     Diabetic PeripheralVascD 

82.     Diabetic Renal Disease

83.     Diarrhea

84.     Drusen of Optic Nerve

85.     Dumping SydroPost Sur 

86.     Dupuytens Contracture

87.     Dyslexic Amblyopia

88.     Dysthymic Disorder

89.     Eczema

90.     Ehlers Danlos Syndrome 

91.     Emphysema

92.     Endometriosis

93.     Eosinophilia-Myalgia Syn 

94.     Epidermolysis Bullosa

95.     Epididymitis

96.     Epilepsy(ies)

97.     Erythma Multiforma

98.     Felty’s Syndrome

99.     Fibromyagia/Fibrositis

100.  Fore Arm/Elbow/Wrist

101.  Friedreich’s Ataxia

102.  Gastritis

103.  GastroEsophgeal Rflx Dis 

104.  Genital Herpes

105.  Glaucoma

106.  Glioblastoma Multiforme 

107.  Grand Mal Seizures**

108.  Graves Disease

109.  Hemiparesis/plegia

110.  Hemophilia A

111.  Hempery

112.  Henoch-Schoelein Purpur 

113.  Hepatitis-non-viral

114.  Herpetic infection of penis 

115.  Hiccough

116.  Hip

117.  Hodgekins disease

118.  Huntingtons Disease

119.  Hypertension

120.  Hyperventilation

121.  Hypoglycemia(s)

122.  Impotence, Psychogenic 

123.  Insomnia

124.  Intermittent Explosive Dis 

125.  Intervertebral Disk Diseas

126.  Irritable Bowel Synd

127.  Ischemic Heart Disease

128.  IVDD Cerv w Myelopathy 

129.  Jacksonian Epilepsy**

130.  Knee, ankle & foot injury

131.  Legg Calve Perthe Dis 

132.  Limbic Rage Syndrome** 

133.  Lipomatosis

134.  Lower Back Pain

135.  L-S disk dis sciatic N irrit 

136.  Lumbosacral Back Diseas x

137.  Lupus

138.  Lyme Disease

139.  Lympho & reticular ca

140.  Lymphoma

141.  Macular Degeneration

142.  Major Depression, Recurr 

143.  Major Depression, Sgl Epi 

144.  Malignant Melanoma

145.  Mania

146.  Marfan syndrome

147.  Mastocytosis

148.  Melorheostosis

149.  Meniere's Disease

150.  Menopausal syndrome

151.  Migraine(s)

152.  Migraine, Classical

153.  Mononeuritis lower limb 

154.  Motion Sickness

155.  Mucopolysaccharoidosis 

156.  Multiple joints pain

157.  Multiple Sclerosis

158.  Muscle Spasm

159.  Muscular dystrophies

160.  Myeloid leukemia

161.  Myofacial Pain Syndrme

162.  Nail patella syndrome

163.  Nater’s Syndrome

164.  Nausea

165.  Nephritis/nephropathy

166.  Neurasthenia

167.  Neurodermatitis

168.  Neuropathy

169.  Nightmares

170.  Nonpsychotic Org Bra Dis

171.  Nystagmus, Congenital

172.  Obesity, exogenous

173.  Obesity, morbid

174.  Obsessive Compulsive Di 

175.  Opiate Dependence

176.  Optic neuritis

177.  Org Mental Dishd inj

178.  Osgood-Schlatter

179.  Osteoblastoma Ischium

180.  Osteogenesis imperfecta 

181.  Osteoporosis

182.  Other arthropod borne dis 

183.  Other CNS demyelinating 

184.  Other Skin Cancer

185.  Other spinal cord disease 

186.  Pain, Ureter

187.  Pain, Vaginal/Pelvic

188.  Pancreatitis

189.  Panic Disorder

190.  Paralysis, unspecified

191.  Paraplegia(s)

192.  Parkinsons Disease

193.  Paroxysmal Atrial Tach

194.  Patellar chondromalacia 

195.  Pelvic Inflammatory Dis 

196.  Pelvic pain

197.  Pemphigus

198.  Peptic Ulcer/Dyspepsia

199.  Peripheral enthesopathies 

200.  Peritoneal pain

201.  Persistent Insomnia

202.  Peutz-Jehgers Syndrme

203.  Phantom Limb Synd

204.  Pneumothorax, Spontaneo 

205.  Polyarteritis Nodosa

206.  Polycystic Kidney

207.  Porphyria

208.  Post Cardiotomy Syndrom 

209.  Post Concussion Sydrome 

210.  Post Polio Syndrome

211.  Post Traumatic Stress Dis 

212.  Post WE Enephalitis

213.  Premenstrual Syndrome 

 214.  Prostate Cancer

215.  Prostate Cancer Adv.

216.  Prostatitis

217.  Pruritus, pruritic

218.  Pschogenic PAT

219.  Psoriasis

220.  Psoriatic Arthritis

221.  Psychogenic Dysuria

222.  Psychogenic Hyperhidrosi 

223.  Psychogenic Pain

224.  Psychogenic Pylorospas

225.  Pulmonary Fibrosis

226.  Pylorospasm Reflux

227.  Quadriplegia(s)

228.  Radiation Therapy

229.  Raynaud’s Disease

230.  Reflex Sympath Dystroph 

231.  Regional Enteri & Crohns 

232.  Reiters Syndrome

233.  Renal Transplant 

234.  Restless legs syndrome

235.  Rosacea

236.  Sarcoma: Head-neck

237.  Schizoaffective Disorder 

238.  Schizophrenia(s)

239.  Scleroderma

240.  Scoliosis

241.  Sedative Dependence

242.  Senile Dementia

243.  Shingles (Herpes Zoster) 

244.  Sjogren’s Disease 

245.  Sleep Apnea Unspecified 

246.  Spina Bifida Occulta

247.  Spinal mm atrophy II

248.  Spinal Stenosis

249.  Spondylolisthesis

250.  Strabismus & other binoc 

251.  Sturge-Weber Disease

252.  Sturge-Weber Eye Syn

253.  Stuttering

254.  Syringomyelia

255.  Tenosynovitis

256.  Tension Headache

257.  Testicular Cancer

258.  Testicular torsion

259.  Thallasemia

260.  Thoracic Outlet Synd

261.  Thromboangiitis Obliteran 

262.  Thyroiditis

263.  Tic disorder unspec

264.  Tic Doloroux

265.  Tietze’s Syndrome

266.  Tinnitus

267.  TMJ Sydrome

268.  Tobacco Dependence

269.  Tourette's Syndrome

270.  Trachoria Growths***

271.  Tremor/Invol Movements

272.  Trichotillomania

273.  Ureter spasm calculus

274.  Urethritis/Cystitis

275.  Uterine cancer

276.  Vertebral disloc unspec

277.  Viral B Hepatitis, chronic 

278.  Viral C Hepatitis, chronic 

279.  Vomiting

280.  Weber-Christian Dis

281.  Whiplash       

282.  Writers’ Cramp

I want a Colorado Medical Marijuana physician to issue my "medical marijuana certificate"

based upon the medical records  (documentation) I will fax to 303-388-8040,

my submission of this form, and payment of the  medical

marijuana certificate fee via my e-payment here.

 

 

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Colorado Medical Marijuana Associates

44 Cook Street, Suite 100

Denver, Colorado 80206
www.cmedsassoc.com
Phone:303-398-7037

Fax:303-388-8040

 

 

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