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I,________________________________________, (Patient's Name}, understand that medical marijuana is a medicine used in treating the suffering caused by serious and debilitating medical conditions including: Cancer, HIV/AIDS, Epilepsy, Multiple Sclerosis, Parkinson's dis ease, ALS (Lou Gehrig's disease}, damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spastic ity （任何脊髓损伤}，炎症性肠病，亨廷顿疾病，慢性浪费，恶病质，严重或慢性疼痛，癫痫发作，癫痫发作，严重或持续性肌肉痉挛，青光眼或创伤后应激障碍或后肌肉或后后部性应激障碍（PTSD}（PTSD}；如果使用医用大麻，则“可以合理地预计可以放心”此外，医用大麻还用于治疗其他慢性或持续的医学症状，如果不缓解，可能会对患者的安全，身体或心理健康造成伤害。
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