IRIEHEALTH PATIENT INTAKE FORM

Last Name: *

Are you on any medications? List or provide list.

Do you have a Primary Care doctor?

Yes

No

Emergency contact: *

SOCIAL HISTORY. Select all that apply:

Single

Married

Significant other

Other

First Name: *

PAIN LOCATION. Briefly describe the pain location.

Weight: *

Signed: *

Pregnant?

Yes

No

Email: *

Check here to receive email updates

Height: *

Zip:

Vitamins/Supplements?

Date and time *

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.

Phone *

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

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?

Phone *

Surgical History/Dates:

Last physical or lab work.

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