IRIEHEALTH PATIENT INTAKE FORM

I understand that the evaluation, diagnosis and treatment by Dr. Johnson at IRIE Natural Health Center, may include, but is not limited to: ● Intake ● Physical examination ● Botanical medicine including cannabinoid medicine ● Bioidentical hormone replacement therapy ● Homeopathic remedies ● Nutritional Medicine (nutritional supplements, intravenous (IV) micronutrient therapy and intramuscular (IM) injection therapy) ● Dietary Counseling ● Telemedicine ● Acupuncture and Cupping ● Prescription medication to be filled at pharmacy ● Over- the counter medications As with all forms of medicine, I understand I am informed that there are risks and benefits with evaluation, diagnosis, and treatment, including but not limited to: Potential Risks: discomfort or minor bruising from Acupuncture or cupping: allergic reaction to prescribed herbs, supplements, or prescription medicine; a temporary aggravation of preexisting symptoms. Potential Benefits: restoration of the body’s optimal functioning capacity, relief of pain and/or disease symptoms, assistance in disease or injury recovery, and prevention of disease progression or recurrence. Notice to Pregnant Women: all female patients must alert Dr. Johnson if they know or suspect that they are pregnant, as certain therapies could pose a risk to pregnancy. Including medical marijuana and the potential dangers to fetuses caused by smoking or ingesting marijuana while pregnant or to infants while breastfeeding. By signing below, I acknowledge that I have been provided ample opportunity to read this form, or that it has been read to me. I understand that it is my responsibility to request that Dr. Johnson explain all therapies and procedure to my satisfaction during our consultations and I acknowledge that no guarantees have been offered to me concerning the results intended from the treatment Furthermore. I acknowledge and agree that in the event of a medical emergency or when urgent medical care is necessary, I will seek urgent care or go to the nearest emergency room. I intend for this consent form to cover the entire course of the treatment for my present condition, as well as any future conditions for which I may seek treatment at IRIE Natural Health Center. *** By signing this document I am agreeing that the information given is to the best of my 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. *

I agree

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

Patient phone: *

Using Contraceptives?

Yes

No

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

Contact Phone: *

First Name: *

PAIN LOCATION. Briefly describe the pain location.

Weight: *

Pregnant?

Yes

No

Email: *

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Vitamins/Supplements?

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

State: *

Allergies to medications/Reactions?

What is your goal for today?

Address: *

Do you exercise regularly? Describe.

Zip:

Do you have any diet restrictions?

Yes

No

Last Name: *

Do you have a Primary Care doctor?

Yes

No

Signed Dated *

Height: *

Surgical History/Dates:

Last physical or lab work.

Are you on any medications? List or provide list.

Emergency contact: *

SOCIAL HISTORY. Select all that apply:

Single

Married

Significant other

Other

Supply dates of above studies.

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