IRIEHEALTH PATIENT INTAKE FORM

How frequently?

1-2 per week

2-3 per week

DOB: *

Form of Identification *

Arizona driver's license

Arizona State ID

Passport

Height: *

Last Name: *

* required field.

Since last visit has your pain?

Improved quality of life

Decreased pain

Improved sleep

Improved mood

Are you currently taking pain medication?

Yes

On a scale of 1-10 what is the maximum severity experienced ? 0 - no pain 10 (severest)

Duration?

4-6 hours

Days

Do you have children?

Yes

On a scale of 1 - 10 what is your energy level?

RENEWAL 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

Have you had any side effects from the pain medication?

Yes

Are you currently employed?

Yes

Retired

If this is a renewal has MMJ?

Improve quality of lie

Decreased pain

Improved sleep

Improved mood

Does your pain interfere with your sleep?

Yes

Contact Phone: *

What makes your condition worse?

Zip:

SOCIAL HISTORY. Select all that apply:

Single

Married

Significant other

Other

First Name: *

Do you receive food stamps/SNAP?

Yes

Do you have headaches?

Yes

Issue date: *

Do you drink alcohol?

Yes

Occasionally

Is your condition getting progressively worse?

Yes

Address: *

Patients seeking MMJ Certificate renewal may do so by videoconference. Facetime, WhatsApp, Skype , hangouts and such apps may come in handy. Here is a list of what is needed to be attached to complete the video consultation.

Signed Patient Attestation form (needs to be printed from the website and signed. Take a picture and send it back).
Complete this Renewal form.
Attach a photocopy of your driver's license, passport picture, or state issued id photo.
A headshot, selfie.
Medical marijuana card if current.
Food stamps SNAP verification for state discount if applicable.
Pay for Renewal in the SHOP.

Please call the scheduling nurse for an appointment at 480-341-9400. If using SNAP send a photocopy.

You may consult our PRICING list for fee for services information.

What is your cannabis usage experience?

New

Moderate

Experienced

How many hours a night do you sleep?

City: *

Have you had any surgeries related to this condition?

Yes

Do you smoke cigarrettes?

Yes

TELEMEDICINE AVAILABLE

What is your preferred video conferencing app? *

Skype

Facetime

Hangouts

State: *

Weight: *

Would you like to be notified of any medical marijuana clinical studies?

Yes

Upload File

What makes your condition better?

ID number *

Email: *

Check here to receive email updates

If yes occupation?

On a scale of 1-10 what is the severity of your current pain? 0 - no pain 10 (severest)

Signed Dated *

IRIE NATURAL CENTER FOR HEALTH

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