1. Please Enter Your Information.
Last 4 #SSN
Date of Birth
MM slash DD slash YYYY
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
How Did You Hear About Us?
Google/ Search Engine
Google/ Search engine
2. Please upload a legible image of your valid State Driver's License or State Issued ID Card. Your name, date of birth, license or document number and expiration must be visible.
Max. file size: 1 MB.
3. Please provide the following information about your Emergency Contact:
Emergency Contact Full Name
Emergency Contact Email:
Emergency Contact Phone:
4. Are you Renewing your Illinois Medical Marijuana Card?
5. When does your Illinois Medical Marijuana Card expire?
6. Please upload a CLEAR image of your valid illinois Medical Marijuana Card Your name, Issued Date , Expiration Date and Patient Registry Number number must be VISIBLE.
Max. file size: 1 MB.
Illinois Qualifying Condition(s) Illinois Medical Marijuana Program has designated 52 medical conditions that make an individual eligible for treatment with medical marijuana.
7. Please select your qualifying condition(s) for which you seek treatment with medical marijuana:
PTSD - Post-traumatic Stress Disorder
Epilepsy or another seizure disorder
ALS - Amyotrophic Lateral Sclerosis
MS - Multiple Sclerosis
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Traumatic brain injury
CRPS (complex regional pain syndrome Type II)
Irritable bowel syndrome (IBS)
Neuro-Behcet's autoimmune disease
Reflex sympathetic dystrophy
Polycystic kidney disease
Residual limb pain
Spinal cord disease (including but not limited to Arachnoiditis)
Spinal cord injury (damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity)
Superior canal dehiscence syndrome.
8. Have you received a diagnosis of schizophrenia?
9. If you selected "Chronic Pain" as your qualifying condition. Please select your condition(s) from the following list. If one is not listed that affects you, please select "Other" and provide details.
Joint pain, chronic
Back pain, chronic
Degenerative disk disease
Failed back surgery
Neck pain, chronic
Headache, recurrent (i.e. migraine)
Herniated disk(s) of the spine
Irritable Bowel Syndrome (IBS)
Premenstrual syndrome, severe
Reflex Sympathetic Dystrophy (RSD)
Tendinitis & Bursitis
Vertebral compression fracture(s)
Blepharospasm (spasms of the eyelids)
Muscle spasms, chronic
Rheumatoid Arthritis (RA)
Cyclical vomiting syndrome
Gout or Pseudogout
Peripheral arterial disease
Using marijuana including medical marijuana may compromise your relationship with your pain management physician or clinic up to and including termination from their program. Using cannabis from any source may also prevent acceptance into some pain management programs. Obtaining a State of Michigan medical marijuana card (even without using any form of cannabis products) may also be a violation of their policy. Please proceed with caution, and if possible, discuss your decision in advance with your physician.
Please list doctors (name, address and phone number) that you have seen for reasons related to the qualifying condition for which you seek treatment with medical marijuana. We will NOT contact any of these doctors without your written consent.
11. Please provide the following information about your qualifying condition. If you have checked more than one condition, please provide as much information as possible. When were your first diagnosed with this condition?
Are you presently being treated for this condition?
Have you experienced side-effects from your treatment?
Are you considered disabled from your condition?
Do you believe that your current treatment is effective?
Is your condition considered terminal?
12. PREGNANCY RISK: Women should not consume cannabis products while planning to become pregnant, during pregnancy or while breast feeding. What is your risk for pregnancy?
Not at risk (age, surgical, other)
Contemplating pregnancy soon
Not at risk - preventative measure in place
13. MEDICATIONS: Please list any prescribed medications that you currently take.
14. Do you have an allergy to any medication?
15. ALLERGIES: Please list your allergies to medications
16. Have you had surgery in the past?
17. PAST SURGICAL HISTORY: Please list your surgeries, the reason for the operation and approximate date (year).
Type of Surgery
18. Do you have any significant Family History of conditions that relate to your qualifying condition?
19. If Yes, you have significant Family History of conditions that relate to your qualifying condition. What is the relation of those family members and what is the Significant Condition that runs in the family?
20. Do you use any of the following? Check all that apply. Tobacco
In the past
21. Tobacco: Please provide details regarding the frequency and quantity of your tobacco use.
22. Do you use any of the following? Check all that apply. Alcohol
In the past
23. Alcohol: Please provide details regarding the frequency and quantity of your alcohol consumption.
24. Do you use any of the following? Check all that apply. Illicit drug use (excluding marijuana)
In the past
In a Treatment Program
25. Illicit drugs: Please provide details regarding the nature of your drug use.
26. Please provide any additional information that you consider relevant for the physician to know before your evaluation.
Documentation of Qualifying Condition At this time, upload any relevant medical documentation you would like to be considered in the approval of your Illinois Medical Marijuana Card. **Please note that the diagnosis on the medical records must be relevant to your qualifying recondition. The records should clearly show your name as well as the name of the physician treating you** If you do not have any medical records, or you are unsure how to obtain them, our Patient Coordinator Team will help your through that process after you have completed this intake form.
27. Please upload your medical records that document your qualifying condition.
Max. file size: 1 MB.
Faxing Your Medical Records Be sure to fax your medical records as soon as possible so that we are able to help you get registered on the day of your appointment. When your records are received, we will review them to determine if they are sufficient to recommend medical marijuana. If additional information is needed, we will follow up with you. Fax Recipient: Athena Certification Center, LLC Fax Number: 419-237-7118
Emailing Your Medical Records Be sure to email your medical records as soon as possible so that we are able to help you get registered on the day of your appointment. When your records are received, we will review them to determine if they are sufficient to recommend medical marijuana. If additional information is needed, we will follow up with you. Email Subject: [Patient Name] - Medical Records Email:
Need Help Obtaining Medical Records Give us a call at (419)237-7119
Qualifying Condition Assessment
28. From what company, organization or physician did you receive your prior medical marijuana card?
29. Are you an active police officer, fire fighter, probation officer, or any type of law enforcement?
30. Do you hold a CDL or school bus driver's license?
31. Have you ever used marijuana during the same time period in which you have had your Qualifying Condition?
32. Please indicate your expectations from the use of Medical Marijuana. Select all that apply.
Reduce or eliminate the use of opiates
Decrease muscles spasms
Improve sleep quality
Decrease or eliminate the use of alcohol
Improve my sense of wellbeing
Reduce the use of medications
Reduce intra-ocular pressure
My signature below attests to the fact that I have accurately and completely disclosed the requested information and indicates that I give permission to Athena Certification Center LLC (dba My Marijuana Card) to disclose any information regarding my treatment to Illinois Medical Marijuana Program so that I can be registered as an active medical marijuana patient.