DOC request three complete - Cannabis Defense Coalition

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cm:~EVANS, TRISTA R.
324594 11/04/1974
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. J£::.lVeo
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518087679
(~ STATI!OFWASHINGTON
. FEB 09 2009 .
......, DePARTMSNl OF COFtlttCTIONS
MedicInal Use of Marijuana Verification
Depl"ofc .
OlT~ctions HI"
ea til ,:,ervices
To be filled out by Prescrlbet:
Dear Prescriber,· .
By staw statute the Washington State Department of Corrections Is charged with the responsibility to sup~~ise sOn)e
offendel'S after they have been convicted of a felony. The above named patIent is currently under supervtslon by the
Departroent. SupervIsion Is designed to help the offender ~void those environments or situations that lead to their criminal
behavior. Often illicit dl'Ug use is a contributing factor in an individual's crIminallty_ Accordingly it's usual that the court: or
th~ Department of Cotractions will Impose a condition of supervision that the offender not use, or possess ilUcitdrlJgs,
Including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has
been recommended_ The belOw. verlfication is to determine the legitimacy of their clclim. Thank you in advance for your
assistance. If you have questions please feel free to perSOnally contact the Medical.Director of the Department at (360)
725--8700. . . . /
1. Is tl)is patient under your care . rz(yes 0 No
2- Are you recommending medical marijuana for his patient due to a diagnosis of Acquired
Immunodeficiency Syndrome (AIDS) DYes ~o
a. If the answer to question 2 is 'Yes', does he/she have anorexia OYe.s oNo
b. If the answer to question 28 is "Yes", ~oes he/she have weight loss7 OVes ONo
3. Are you recommending medica! marijuana for this patient due to nausea and ~omiting
associated with cancer chemotherapy Dyes ~.
a. If the answer to question 3 is "Yes", has the patientfalied to respond to conventional
antiemetic treatments DYes ONo
b_
If the answer to question 3a is "Yes', please descrlbe what thOl;lB treatments were (madication. dose,
duration): '.
c. . What is the planned schedule of che~othe.-apy
4. . If you answered "No· to Items 2. & 3 above, what is the reason you are r.ecornmending medicinal use of
iilarijuana
a. Please provide evidence published in a peer-reviewed sCientific publication to SlJpport the .medicinal use of
marijuana for this purpose
5.
VYhile on community supervislOn(;Parole") the Department of Corr~tions on1y-iUffiOi1zes trie ~yLe-s-"-. -':--O-N-O---
use of the ~r'. synt~~tfc:.f!~ul.~~90 .. ~ ~a~JJuana. If the Department authorizes this patient's arYes.
use of medIcal marijuana, wUr you be prescribing only the oral synthetio formulation
e. The patient's accompanying Release of InformatIon authorizes you to provide the
Department with current an~ future Information related to ttl1S Issue. Dei you agree to notify
the Oepartment's Medical Director of any changes in your answers above
oNo
DOC 1+053 (Rev. 7/31/08)
D00380.200
PDU-6655-3 000238