(Texas) Miracle Leaf Intake Form
Reference layout for recreating in JotForm or Google Forms — all questions, field types, options, and conditional logic shown.
Section 1 — Personal Information
Date of Birth Date
Format: MM/DD/YYYY
Address Address / Autocomplete
Street address with autocomplete lookup
City Short Text *Required
State Short Text *Required
Phone Phone Number
Format: (XXX) XXX-XXXX
Sex Assigned at Birth Dropdown
Options: Male, Female, Intersex (or platform standard options)
Height Short Text
Format: X ft XX in
Weight Number
e.g., in lbs
Last 5 of Your Social Security # Short Text *Required
Texas's Compassionate Use Program (CUP) requires this for provider certification. Enter last 5 digits only.
How Did You Hear About Us? Checkbox (Multiple Select)
Google
Yahoo
Bing
AOL
MSN
Yahoo Friend
Facebook
Other
Section 2 — Identification
Identification Type Radio / Single Select
State Driver's License
Out of State ID
US Passport
Non-US Passport
Military ID
Identification Number Short Text
Upload Your ID — Front File Upload
Accepts image files (JPG, PNG, PDF)
Upload Your ID — Back File Upload
Accepts image files (JPG, PNG, PDF)
Section 3 — Medical Information
Are you currently under the care of a physician? Yes / No
If YES → Show text field: "Provide details"
Have you ever been hospitalized? Yes / No
If YES → Show repeating table with two columns: Date (year) and Reason. User can add and delete rows.
| Date (Year) | Reason / Description | Action |
|---|
| [text field] | [text field] | Delete |
| + Add Row |
Have you been evaluated for the use of medical marijuana by any other physician in the past? Yes / No
Have you been evaluated and denied a medical marijuana recommendation? Yes / No
Have you ever been treated for symptoms of depression, psychosis, attempted suicide, or had any other mental health issues? Yes / No
Have you ever been prescribed medication for any mental health problem? Yes / No
Do you currently see a mental health physician? Yes / No
Section 4 — Symptoms & Patient Medical History
TEXAS Medical Cannabis Qualifying Conditions: Check each medical problem you suffer from, or select "Other" to have the doctor evaluate your unique condition. At least one box must be checked to qualify.
Qualifying Conditions Checkbox (Select All That Apply)
PTSD
A condition that causes chronic pain
Other (doctor evaluates)
Immediate Family Medical Issues
Indicate if you or your immediate family had any of the following problems.
Family / Personal Health History Checkbox (Select All That Apply)
Depression
High Blood Pressure
Other
Section 5 — Social Questions
Do you drink alcohol? Yes / No
Do you smoke cigarettes? Yes / No
Do you have medical records confirming your diagnosis? Dropdown
Presented as a searchable dropdown (e.g., Yes / No / Not Sure)
Section 6 — PTSD Questionnaire
Scale for Q1–Q20 (Radio Button, Single Select each):
• Sometimes • Moderate • Most of the Time • Always • None of the above
Describe Your Worst Event Long Text / Paragraph
Free-text — patient describes their traumatic event
Rate each of the following (Sometimes / Moderate / Most of the Time / Always / None of the above)
Q1. Repeated, disturbing, and unwanted memories of the stressful experience?
Q2. Repeated, disturbing dreams of the stressful experience?
Q3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Q4. Feeling very upset when something reminded you of the stressful experience?
Q5. Having strong physical reactions when something reminded you of the stressful experience?
e.g., heart pounding, trouble breathing, sweating
Q6. Avoiding memories, thoughts, or feelings related to the stressful experience?
Q7. Avoiding external reminders of the stressful experience?
e.g., people, places, conversations, activities, objects, or situations
Q8. Trouble remembering important parts of the stressful experience?
Q9. Having strong negative beliefs about yourself, other people, or the world?
e.g., "I am bad," "there is something seriously wrong with me," "no one can be trusted," "the world is completely dangerous"
Q10. Blaming yourself or someone else for the stressful experience or what happened after it?
Q11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Q12. Loss of interest in activities that you used to enjoy?
Q13. Feeling distant or cut off from other people?
Q14. Trouble experiencing positive feelings?
e.g., being unable to feel happiness or have loving feelings for people close to you
Q15. Irritable behavior, angry outbursts, or acting aggressively?
Q16. Taking too many risks or doing things that could cause you harm?
Q17. Being "superalert" or watchful or on guard?
Q18. Feeling jumpy or easily startled?
Q19. Having difficulty concentrating?
Q20. Trouble falling or staying asleep?
Reference document — (Texas) Miracle Leaf Intake Form — Heally Platform