IRIEHEALTH PATIENT INTAKE FORM

IRIE NATURAL CENTER FOR HEALTH

TELEMEDICINE AVAILABLE

Weight: *

Do you smoke cigarrettes?

Yes

How frequently?

1-2 per week

2-3 per week

DOB: *

Form of Identification *

Arizona driver's license

Arizona State ID

Passport

Height: *

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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?

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RENEWAL FORM

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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

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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

Patient phone: *

Date and time *

What makes your condition worse?

Emergency contact: *

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 supporting documents.
Medical records, if any.
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.
Find and pay for Renewal in the SHOP. Place it in cart and checkout.

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

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How many hours a night do you sleep?

Signed: *

City: *

Email: *

Check here to receive email updates

Have you had any surgeries related to this condition?

Yes

What is your preferred video conferencing app? *

Skype

Facetime

Hangouts

State: *

Contact Phone: *

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

Yes

Upload File *

If yes occupation?

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

What makes your condition better?

ID number *

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