IRIE Natural Medical Marijuana Intake

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Date
Date
Month
Day
Year
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Name* This field is required.
First Name
Last Name
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Date of Birth
Date
Month
Day
Year
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Address* This field is required.
Street Address
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City
State / Province
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Afghanistan
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Ethiopia
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Fiji
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France
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Gabon
The Gambia
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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eSwatini
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Tonga
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Other
Country
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Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
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Emergency Contact Name and Relationship
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Emergency Contact Phone Number
Please enter a valid phone number.
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What form of identification do you have?* This field is required.
Please Select
Please Select
Arizona drivers license,
Arizona state ID
Passport
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What is the issue date?* This field is required.When was the ID issued
Date
Month
Day
Year
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What is the identification number? * This field is required.ID Number
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Do you receive food stamps?* This field is required.
YESNO
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Would you like to be notified of any Medical marijuana clinical studies?* This field is required.
YESNO
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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.
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Signature* This field is required.Informed consent
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Gender* This field is required.
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Please Select
Male
Female
Non-binary/Other
Prefer not to say
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What is your height?* This field is required.
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What is your weight?* This field is required.
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What is your major health concern?* This field is required.
Please Select
Please Select
Cancer
Glaucoma
Human Immunodeficiency Virus (HIV)
Acquired Immune Deficiency Syndrome (AIDS)
Hepatitis C Amyotrophic Lateral Sclerosis (ALS)
Crohn's Disease
Agitation of Alzheimer's Disease
Cachexia or wasting syndrome
Severe and chronic pain
Severe nausea
Seizures, including those characteristic of epilepsy
Severe or persistent muscle spasms, including those characteristic of multiple sclerosis
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Is your condition due to an accident?* This field is required.Automobile, Work, Home, Other
YESNO
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How long have you been experiencing symptoms?* This field is required.
Please Select
Please Select
Less than 6 months
6 months to 1 year
1 to 3 years
3-5 years
More than 5 years
I don't know
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Are you taking any medication?* This field is required.
YESNO
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List all medications you are taking.Prescription medications, Over the counter medications and Supplements
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Ok
Ok
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Do you have any Drug Allergies?* This field is required.
YESNO
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Do you have an allergy to SULFA medications?* This field is required.
YESNO
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List Drug Allergies and Reaction.Include Name of Drug and Allergic Reaction
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Ok
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Are you Pregnant of Breastfeeding?* This field is required.
YESNO
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Do you have any of the following?CHECK ALL THAT APPLY
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Are you experiencing chronic pain?* This field is required.
YESNO
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Please describe the nature of your pain. Is it constant (present all the time) or intermittent (comes and goes)How often do you have the pain?
Please Select
Please Select
Constant
Intermittent
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Is your condition getting progressively worse?* This field is required.
YESNO
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Describe your painCHECK ALL THAT APPLY
1. Dull: Aching or throbbing pain that is not sharp or intense.
2. Sharp: Sudden, intense, and stabbing pain.
3. Stinging: Pain that feels like a sharp, burning sensation.
4. Burning: Persistent pain that feels like a burning sensation.
5. Shooting: Pain that radiates or shoots through a specific area.
6. Cramping: Pain that feels like muscle cramps or spasms.
7. Sore: Pain that is tender or sensitive to touch.
8. Tingling: Pain accompanied by a sensation of pins and needles.
9. Numbness: Lack of sensation or a tingling feeling.
10. Stiffness: Pain accompanied by a feeling of stiffness or reduced mobility.
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Have you had any surgeries related to this condition?* This field is required.
YESNO
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Do you have joint noises?CHECK ALL THAT APPLY
Please Select
Please Select
Clicking
Grinding
Popping
Locking
Swelling
No of the above
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Do you experience headaches?* This field is required.
YESNO
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If you experience headaches, how frequent do you get them?
Please Select
Please Select
1. Daily: Having headaches every day.
2. Several times a week: Experiencing headaches multiple times within a week.
3. Once a week: Having a headache once every week.
4. Once or twice a month: Experiencing headaches approximately once or twice a month.
5. Occasionally: Having headaches sporadically or infrequently.
6. Rarely: Rarely experiencing headaches.
7. Never: Not having any headaches.
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How long do your headaches last?
Please Select
Please Select
1. Minutes: Headaches that last for a few minutes.
2. Hours: Headaches that persist for a few hours.
3. Half a day: Headaches that last for approximately half a day.
4. Full day: Headaches that persist for a whole day.
5. Multiple days: Headaches that last for several consecutive days.
6. Intermittent: Headaches that come and go throughout the day.
7. Chronic: Headaches that are constantly present or occur for prolonged periods.
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On a scale of one to 10 what is the severity of your current pain?
Please Select
Please Select
1. 1 - Minimal pain: Very mild or almost no pain.
2. 2 - Mild pain: Discomfort that is noticeable but not bothersome.
3. 3 - Moderate pain: Pain that is noticeable and may affect daily activities.
4. 4 - Moderate to severe pain: Pain that is noticeable and may require some form of relief.
5. 5 - Severe pain: Intense pain that significantly affects daily activities.
6. 6 - Very severe pain: Excruciating pain that makes it difficult to carry out normal tasks.
7. 7 - Extremely severe pain: Intense pain that requires immediate attention and relief.
8. 8 - Intolerable pain: Severe pain that is unbearable and may require urgent medical attention.
9. 9 - Excruciating pain: Agonizing pain that is almost unbearable.
10. 10 - Worst pain imaginable: The most severe pain possible.
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What makes your condition better?* This field is required.
Please Select
Please Select
1. Medication: Taking prescribed medication or over-the-counter drugs.
2. Rest: Getting enough sleep and allowing your body to heal.
3. Heat or cold therapy: Applying heat or cold packs to the affected area.
4. Physical therapy: Engaging in specific exercises or techniques to improve your condition.
5. Relaxation techniques: Practicing meditation, deep breathing, or yoga.
6. Massage therapy: Receiving massages to alleviate muscle tension or pain.
7. Lifestyle changes: Making adjustments to your diet, exercise routine, or daily habits.
8. Stress management: Implementing stress-reduction techniques such as mindfulness or counseling.
9. Alternative therapies: Trying acupuncture, herbal remedies, or other complementary treatments.
10. Time: Allowing your body to naturally heal and recover over time.
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What makes your condition worse?* This field is required.
Please Select
Please Select
1. Certain foods or drinks: Consuming trigger foods or beverages that worsen your symptoms.
2. Stress: Experiencing high levels of stress or anxiety.
3. Lack of sleep: Not getting enough restful sleep.
4. Certain activities: Engaging in physical activities that strain or exacerbate your condition.
5. Exposure to allergens or irritants: Coming into contact with substances that trigger your symptoms.
6. Skipping medication: Not following your prescribed medication regimen.
7. Poor posture or ergonomics: Maintaining incorrect posture or using improper ergonomics.
8. Overexertion: Pushing yourself too hard physically and not allowing for proper recovery.
9. Weather changes: Reacting to changes in temperature, humidity, or barometric pressure.
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Does your condition interfere with activities and daily living? * This field is required.
Please Select
Please Select
Work
Sleep
Daily activities
Recreation
Sports
Hobbies
No, I am able to carry out my daily activities without any interference from my condition.
Other
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What activities/movements are difficult or painful to perform?
Please Select
Please Select
Sitting
Standing
Bending
Walking
Lying down
Getting up
Turning neck or trunk
Kneeling, or squatting
Driving
Lifting
Other
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What treatments or therapies have you tried?
Please Select
Please Select
Physical therapy
Chiropractic
Massage
Acupuncture
Pain injections
Medication
Other
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Does pain interfere with your sleep
YESNO
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If your medical condition is not related to chronic pain and you are experiencing other symptoms, such as nausea, gastrointestinal problems, seizures, or another condition, please briefly describe your symptoms if not listed above, and provide any further information about your condition.
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Ok
Ok
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What is your cannabis usage experience?* This field is required.
Please Select
Please Select
New
Moderate
Experienced
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If this is a Medical marijuana renewal what have been the effects of Medical marijuana on your health?
Please Select
Please Select
Improve quality of life
Decreased pain
Improve sleep
Improve mood
Improve appetite
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