IRIEHEALTH PATIENT INTAKE FORM

Emergency Contact: *

SOCIAL HISTORY. Select all that apply:

Single

Married

Significant other

Other

PAIN LOCATION. Briefly describe the pain location.

Weight: *

Pregnant?

Yes

No

Email: *

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Height: *

Zip:

City: *

Vitamins/Supplements?

Rate your Pain today: (0 - no pain; 10 - worst possible).

Do you have any diet restrictions?

Yes

No

State: *

Allergies to medications/Reactions?

What is your goal for today?

Address: *

Do you exercise regularly? Describe.

Contact Phone: *

By signing this document you are agreeing that the information given is to the best of your knowledge. As part of the intake the doctor will base their recommendation on the information given. I certify that the information provided in this document is true to the best of my ability.

If "yes" describe

Name of primary care doctor:

Do you have children?

Yes

No

Breastfeeding?

Yes

No

DOB: *

Have you ever consulted a Naturopathic Physician, Nutritionist, Counselor or other Alternative healthcare provider?

Yes

No

Supply dates of above studies.

Using Contraceptives?

Yes

No

Do any of the above run in your family? Who?

Surgical History/Dates:

Last physical or lab work.

Last Name: *

Are you on any medications? List or provide list.

Do you have a Primary Care doctor?

Yes

No

First Name: *

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