IRIEHEALTH PATIENT INTAKE FORM

Sign *

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.

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

Weight: *

Pregnant?

Yes

No

Email: *

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City: *

Vitamins/Supplements?

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: *

Using Contraceptives?

Yes

No

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

Surgical History/Dates:

Last physical or lab work.

Last Name: *

Signed Dated *

First Name: *

PAIN LOCATION. Briefly describe the pain location.

Height: *

Zip:

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

Supply dates of above studies.

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

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