Dr. Bob Blake

Bob E. Blake, M.D. is a former Emergency Department Physician and Senior Partner with California Emergency Physicians Medical Group, who now limits his practice exclusively to medical marijuana evaluations. During his career in Emergency Medicine he served as Chairman of the Department of Emergency Medicine and Chief-of-Staff at Pomerado Hospital in Poway, California. Dr. Blake now serves as an Independent Medical Examiner and provides comprehensive forensic evaluations of patients to see if their medical condition qualifies them for coverage under California Health and Safety Code section 11362.5

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Medical Marijuana Survey by Dr. Bob Blake
First Name
 
Last Name
 
Email
 
Date of Birth(DOB)
 
Phone Number ( (area code) xxx-xxxx ) )
 
READ the following carefully before continuing
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Please Answer the Questions to the Best of your Ability.
The questions are in numbered groupings per set.
It is imperative that you answer each question to complete the test as well as fill out the
information at the top of the page.
First and Last Name,email, date of birth. Phone number is optional.
ALL QUESTIONS MUST BE ANSWERED IF THEY ARE RELEVANT TO YOU OR NOT.

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1. Do you have HIV/AIDS?
Yes No
1a. Are your activities of daily living affected?
Yes No
2. Do you have glaucoma?
Yes No
2a. Is your glaucoma worsening or are you on medicine?
Yes No
2b. Is your glaucoma affecting vision or activities of daily living?
Yes No
3. Do you suffer from seizures/epilepsy?
Yes No
3a. Are your seizures difficult to control?
Yes No
3b. Are your activities of daily living affected?
Yes No
4. Do you suffer from muscle spasms?
Yes No
4a. Do you suffer from chronic pain?
Yes No
4b. Are your activities of daily living affected?
Yes No
5. Do you suffer from arthritis? [HI residents must have arthritus with chronic pain]
Yes No
5a. Do you suffer from chronic pain?
Yes No
5b. Are your activities of daily living affected?
Yes No
6. Do you suffer from migraine headaches? [HI residents must have migraine headaches with chronic pain]
Yes No
6a. Are your migraine headaches difficult to control?
Yes No
6b. Are your activities of daily living affected?
Yes No
7. Do you suffer from chronic anorexia? [HI residents skip this question]
Yes No
7a. Are you having trouble stimulating your appetite or are you losing weight?
Yes No
7b. Are your activities of daily living affected?
Yes No
8. Do you suffer from cachexia/wasting syndrome?
Yes No
8a. Are your activities of daily living affected?
Yes No
9. Do you suffer from multiple sclerosis?
Yes No
9a. Do you suffer from chronic pain or muscle spasms?
Yes No
9b. Are your activites of daily living affected?
Yes No
10. Do you suffer from chronic nausea?
Yes No
10a. Are your activities of daily living affected?
Yes No
10b. Is your nausea difficult to control?
Yes No
11. Do you suffer from PTSD (post traumatic stress disorder)? [HI residents skip this question]
Yes No
11a. Are your activities of daily living affected?
Yes No
12. Do you suffer from any other Chronic or Persistent Medical or Psychiatric disorder that either substantially limits your ability to conduct one or more major life activities,or interferes with relationships, or, if not alleviated, may cause serious harm to your safety or physical or mental health [ For Hawaii residents - 'Any other condition must be approved by the Department of Health pursuant to administrative rules in response to a request from a physician ( e.g. Dr. Jimenez) or potentially qualifying patient ](e.g. Premenstrual Dysphoric Disorder (PMDD)/severe menstrual cramps/ severe PMS, Depression, Anxiety, Bipolar/Manic Depressive disorder, ADD/ADHD, Chronic insomnia, severe Grief reaction, Anger reaction or Impulse control disorder, obsessive compulsive disorder, Fibromyalgia/Myositis/Fibromyositis, Irritable bowel syndrome/Spastic colitis, Ulcerative colitis/Inflammatory bowel disease, Sprue disease, Social phobia, severe Flight phobia, other phobias, Somatization, Severe situational maladjustment/Situational stress reaction, Neuralgia/Neuritis/Neuropathy/Neuropraxia, Radiculitis/Radiculopathy, Reflex sympathetic dystrophy syndrome, Sickle cell Anemia with crisis, Restless Leg Syndrome, Interstitial Cystitis, Cerebral palsy, Paraplegia, Quadriplegia, Spinal cord injuries, severe to moderate Brain injuries, Tremors, Parkinson's, Huntington's, Dystonia's, Tourette syndrome, Degenerative Disc disease, Spasmodic torticollis, Alzheimer's, Raynaud's Phenomenon, Dysparenia,Hepatitis C or other Chronic Hepatitis, Meniere's, Amyotrophic Lateral Sclerosis, Diabetes Mellitus, Gliomas, Urinary Incontinence, Chronic Pruritus, Sleep Apnea, Opiate ( e.g., Vicodin, Norco, Oxycodone) dependence/ Benzodiazepine (e.g., Ativan, Valium, Xanax) dependence/ Alcohol dependence/ Crystal methamphetamine dependence/ Cocaine dependence/ Heroin dependence or other Prescription or illicit drug dependence )
Yes No
12a. Are your activities of daily living affected?
Yes No
12b. Was there poor or no response to past medical treatments?
Yes No
13. Do you have cancer?
Yes No
13a. Are your activities of daily living affected?
Yes No
13b. Do you suffer from chronic pain?
Yes No
14. Do you suffer from Asthma or COPD (Chronic obstructive pulmonary disease)? [HI residents skip this question]
Yes No
14a. Are your activities of daily living affected?
Yes No
14b. Was there a poor response or unfavorable reponse to past medical treatments?
Yes No
15. Do you suffer from an inflammatory bowel disease (i.e. Crohn's disease or Ulcerative Colitis) ?
Yes No
15a. Do you suffer from chronic pain or muscle spasm?
Yes No
15b. Are your activities of daily living affected?
Yes No
16. Do you suffer from chronic pain?(e.g. Chronic back/neck pain, Chronic headaches, Chronic Sciatica, Chronic abdominal or pelvic pain, Complicated post-operative pain, Perineal pain, or other chronic or persistent pain that substantially limits your ability to conduct one or more major life activities, or interferes with relationships, workplace, sleep, and/or if not alleviated, may cause serious harm to your safety or physical or mental health.)
Yes No
16a. Are your activities of daily living affected?
Yes No
16b. Is your pain difficult to control?
Yes No
17. Are you on disability ? (Note: Mental disorders, and Joint/Muscle/Connective tissues and Back injuries are leading causes of disability in the United States)
Yes No
17a. Is your disability permanent?
Yes No
18. Have you tried one or more drugs and, or medical regimens for your condition and resulted in a poor or unfavorable response of both?
Yes No
18a. Did you experience any unwanted side effects or reactions from one or more drugs [Prescription or Over the counter]?
Yes No
18b. Are you concern of about possible side effects or reactions from drugs (Prescription or Over the counter) and this resulted in a decision that you will not fill a prescription or take a drug(s).
Yes No
19. Has Cannabis (Marijuana) provided relief for your condition?
Yes No
19a. Have you self discontinued or limited your use of cannabis because fear of prosecution?
Yes No
19b.You have chosen to exercise the Medical Marijuana Laws and received a Medical Marijuana recommendation which will allow you to use, possess, and grow medical marijuana legally, so you can use the medicinal value of cannabis without the fear of prosecution?
Yes No