IRIEHEALTH PATIENT INTAKE FORM

Epilepsy/Seizures

Yes

Past

Not sure

Patients may seek consultation by video conference. Facetime, WhatsApp, Skype , Hangouts and such apps may come in handy.

Fill out this form.

Here is a list of what is needed to be attached to complete the video consultation.

Attach a photocopy of your Arizona driver's license, passport picture, or Arizona state issued id photo.
A headshot, selfie.
Attach supporting medical records, if any.
Pay for Weight Loss product in the SHOP or in Weight Loss page.

Please call the scheduling nurse for an appointment at 480-341-9400.

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

Do you drink coffee?

Yes

Do you take any supplements?

Yes

Do you drink alcohol?

Yes

Diabetes

Yes

Past

Not sure

Are you currently employed?

Yes

Retired

Last Name: *

Date and time *

Heart Palpitations

Yes

Past

Not sure

WEIGHT LOSS

High cholesterol

Yes

Past

Not sure

Do you often eat out?

Yes

Dizziness

Yes

Past

Not sure

First Name: *

Do you eat 3 meals a day?

Yes

Have you been on a wieght loss program before?

Yes

State: *

* required field.

Anxiety/Depression

Yes

Past

Not sure

Heart Trouble

Yes

Past

Not sure

Irregular menstruation

Yes

Past

Not sure

Do you drink soda?

Yes

Leg cramps

Yes

Past

Not sure

List all your supplements

Fatigue

Yes

Past

Not sure

TELEMEDICINE AVAILABLE

Do you crave sweets?

Yes

List any known allergies

Hepatitis C

Yes

Past

Not sure

Frequent headaches

Yes

Past

Not sure

Hepatitis B

Yes

Past

Not sure

List all your medications

Sex: *

Allergies

Yes

Past

Not sure

Female organ problems

Yes

Past

Not sure

Primary Care Physician:

Bowel issues/Constipation

Yes

Past

Not sure

Do you drink energy drinks?

Yes

Do you exercise?

Yes

Cancer

Yes

Past

Not sure

Thyroid issues

Yes

Past

Not sure

DOB: *

Your statement of health is

Excellent

Good

Fair/Poor

Zip:

HIV

Yes

Past

Not sure

Patient phone: *

Allergic to Lidocaine

Yes

Past

Not sure

Chronic low blood pressure

Yes

Past

Not sure

Shortness of breath

Yes

Past

Not sure

Email: *

Check here to receive email updates

Emergency contact: *

Have you ever had or do you currently have:

Glaucoma

Yes

Past

Not sure

Do you take any medications??

Yes

Pregnant or breast feeding?

Yes

Past

Not sure

Do you crave carbs?

Yes

Do you smoke?

Yes

Past

Not sure

Fibroids/Ovarian cysts

Yes

Past

Not sure

History of substance abuse

Yes

Past

Not sure

Contact Phone: *

What is your goal weight?

Difficulty Sleeping

Yes

Past

Not sure

High Blood Pressure

Yes

Past

Not sure

Gall Bladder issues

Yes

Past

Not sure

Kidney trouble

Yes

Past

Not sure

City: *

PATIENT CONSENT The above information is a true representation of my current health status. I Have read and understand the above and hereby agree to treatment administered to me, including medications for weight loss. The undersigned, having been informed by Irie Natural Center for Health of the hazards and possible consequences involved in treatment by medications, supplements injections and nonetheless consent to such treatment and agree to hold Irie Natural Center for Health harmless of any claims, demands or suits for damage from any injury or complications whatsoever, save negligence, that may result in such treatment. I am also aware this a no guarantee for medication and/or treatment. Notice: All tpatients may receive medications dispensed by physican (or receive written prescription) to take to a pharmacy of their choice for a fee. We have the right to refuse service. Should you pursue a chargeback through your credit card company, or otherwise accrue on unpaid balance, you forfeit your right to privacy and the information required to pursue collection and/or legal action will be disclosed in seeking remuneration IF YOU SUSPECT YOU ARE PREGNANT DISCONTINUE ALL MEDICATIONS, SUPPLEMENTS or INJECTIONS. PREGNANT OR NURSING MOTHERS SHOULD NOT BE TAKING THIS MEDICATION. *

I agree

Phenylketonuria (PKU)

Yes

Past

Not sure

Address: *

Height: *

Signed: *

Do you crave salt?

Yes

TELEMEDICINE AVAILABLE

IRIE NATURAL CENTER FOR HEALTH

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