General Intake Form
Reference layout — Default questions (all states) + Texas-specific conditional questions only.
Intro text: "Please fill out your updated medical health history prior to connecting to your provider:"
Section 1 — Personal Information
First Name Short Text
attr: first_name | loads from patient profile
Middle Name Short Text
attr: middle_name | loads from patient profile
Last Name Short Text
attr: last_name | loads from patient profile
Date of Birth Date
Format: MM/DD/YYYY
attr: birthdate | loads from patient profile
Address, Apartment, City, State, ZIP Address (Autocomplete)
Loads address from patient profile. Sub-fields: Apartment, City, State, Zip code
attr: address
Phone Number Phone
attr: phone | loads from patient profile
Alternative Phone Number Phone
attr: alternative_phone | loads from patient profile
Are you filling this out for a minor? Conditional Branch
attr: minor
If YES → show all three sub-fields + instruction text:
First name of minor Short Text *Required
attr: first_name_of_minor
Last name of minor Short Text *Required
attr: last_name_of_minor
Date of Birth of minor Date MM/DD/YYYY *Required
attr: date_of_birth_of_minor
Also show text block: "Please fill out the rest of the questions on behalf of the minor."
If NO → continue normally
Sex Radio / Single Select
attr: sex | loads from patient profile
MaleFemaleIntersex
Gender Short Text / Dropdown
attr: gender | loads from patient profile
Height Short Text
attr: height | loads from patient profile
Weight Number
attr: weight | loads from patient profile
Section 2 — Texas-Specific: Compliance & Identity
The following questions appear only for Texas patients (tagged person_pin = Texas in the form builder).
Last 5 of Your Social Security # Texas Only *Required
Texas's Compassionate Use Program (CUP) requires that your provider when certifying the patient provides the last five of the patient's social security number. Please enter the last five of your social security number below.
attr: ssn
Are you currently on probation or parole? Texas Only
attr: probation_or_parole
No
Yes – State-level supervision
Yes – Federal-level supervision
Prefer not to answer
Informational note shown after this question (Texas only):
"Being on probation or parole does not automatically disqualify you from participating in the Texas Compassionate Use Program (TCUP). Many patients on state supervision are eligible and currently enrolled, although it's still recommended you discuss with your supervising officer. If you are on federal probation or parole, please confirm with your supervising officer before purchasing medication, as federal rules may differ from state protections."
What medical condition qualifies you for medical cannabis in Texas? Texas Only Has "Other" branch
Please refer to the Texas Department of Public Safety under the Compassionate Use Program for a full list of conditions that meet criteria for the use of medical cannabis.
attr: primary_conditions
Neuropathy
Seizure Disorder
Amyotrophic Lateral Sclerosis (ALS)
Multiple Sclerosis
Cancer
Autism
Dementia
Parkinson's Disease
Muscle Spasm / Spasticity
PTSD (Previously Diagnosed)
PTSD (Undiagnosed)
Traumatic Brain Injury (TBI)
Epilepsy
Spasticity
Incurable Neurodegenerative Disease
Condition that causes chronic pain
Crohn's disease or other inflammatory bowel disease (IBD)
Terminal illness or any condition for which a patient is receiving hospice or palliative care
Other Neurodegenerative Condition
If "Other Neurodegenerative Condition" selected → show sub-field:
Other Neurodegenerative Condition Short Text
attr: other_neurodegenerative_condition
Section 3 — Medications
Note: The "Are you taking any prescription medications or herbs?" question is shown for all states except Texas and Massachusetts. Texas patients skip this question. Massachusetts patients instead get separate questions for prescription medications and for vitamins/supplements (not included here as they are Massachusetts-specific).
Do you currently use specific medications for your medical condition? Conditional Branch
Shown for all states except Massachusetts.
attr: do_you_currently_use_specific_medications_for_your_medical_condition
NoYesTried it
If YES → show sub-field:
Provide details please Long Text
attr: do_you_currently_use_specific_medications_for_your_medical_condition_provide_details
If "Tried it" → show sub-field:
Provide details please Long Text
attr: do_you_currently_use_specific_medications_for_your_medical_condition_tried_it
If NO → continue
Are you taking any prescription medications or herbs? Conditional Branch
Shown for all states except Texas and Massachusetts.
attr: any_medications_
YesNo
If YES → show sub-field:
Specify your medications or herbs Long Text
attr: specify_your_medications_or_herbs
If NO → continue
Do you have any allergies to any medications? Conditional Branch
attr: any_allergies_to_medications_
YesNo
If YES → show sub-field:
Specify your allergies to any medications Long Text
attr: specify_your_allergies_to_any_medications
If NO → continue
Section 4 — Medical History
Have you ever had any surgeries or been hospitalized? Conditional Branch
attr: have_you_ever_had_any_surgeries_or_been_hospitalized
YesNo
If YES → show sub-field:
Provide details please Long Text
attr: have_you_ever_had_any_surgeries_or_been_hospitalized_provide_details
If NO → continue
Have you experienced or been diagnosed with any of the following? Checkbox (Multi-Select)
attr: have_you_experienced_or_been_diagnosed_with_any_of_the_following
Depression
Bipolar Disorder
Schizophrenia
Suicidal thoughts
ADHD
None
If "Depression" selected → show sub-field:
Depression: Please provide details including any medical treatments Long Text
attr: depression_please_provide_details_including_any_medical_treatments
If "Suicidal thoughts" selected → show sub-field:
Suicidal Thoughts: Please provide as much detail as possible including dates Long Text
attr: suicidal_thoughts_please_provide_as_much_detail_as_possible_including_dates
Are there health/medical problems that occur frequently in your family? Conditional Branch
attr: are_there_health_medical_problems_that_occur_frequently_in_your_family
YesNo
If YES → show sub-field:
Specify health/medical problems that occur frequently in your family Long Text
attr: specify_health_medical_problems_that_occur_frequently_in_your_family
If NO → continue
Do you have a primary care provider? Conditional Branch
attr: do_you_have_a_primary_care_provider
YesNo
If YES → show sub-field:
Please identify Name, Address, Phone Long Text
attr: do_you_have_a_primary_care_provider_please_identify_name_address_phone
If NO → continue
When was the last time you saw your doctor/specialist about these complaints? Date / Short Text
attr: last_time_you_saw_your_doctor_about_qualifying_issue
Provide details on the medical condition and diagnosis: Long Text / Paragraph
attr: provide_details_on_the_medical_condition_and_diagnosis
Section 5 — Lifestyle
Do you exercise? Conditional Branch
attr: do_you_exercise
YesNo
If YES → show sub-field:
How often? Short Text
attr: how_often_do_you_exercise
If NO → continue
Do you smoke tobacco? Conditional Branch
attr: do_you_smoke_tobacco
YesNo
If YES → show sub-field:
How often? Short Text
attr: how_often_do_you_smoke_tobacco
If NO → continue
Do you drink alcohol? Conditional Branch
attr: do_you_drink_alcohol
YesNo
If YES → show sub-field:
How often? Short Text
attr: how_often_do_you_drink_alcohol
If NO → continue
Section 6 — Reproductive Health
Are you pregnant? Yes / No
attr: pregnant
NoYes
Breastfeeding? Yes / No
attr: breastfeeding_
NoYes
Section 7 — Renewal Status
Are you RENEWING your certification (Have you had a certification in the last 10 years)? Yes / No
attr: is_this_a_new_or_renewal_certification
NoYes
Reference document — General Intake Form — Default + Texas conditionals only — Built from Heally form builder source