intake@irishealthgroup.com 1420 River Park Drive Ste 120 Sacramento CA 95815

08:00 AM - 05:00 PM Monday - Friday

1420 River Park Drive Ste 120 Sacramento CA 95815

Service Available (916) 231-4747

Toll Free Number (888) 558-4747

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Pre-Visit Consultation

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Pre-Visit Consultation

Please take a few moments to fill out the information below before your scheduled visit.

This will provide us with helpful information about your health.

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Full Name *

Email *

State

Phone Number *

City

PLEASE ANSWER THE FOLLOWING QUESTIONS

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When was the last time you saw your doctor?

When were you last admitted to the hospital?

What was the problem?

Who prepares your meals?

If your medications are pre-poured, who does that?

Who drives you to appointments?

Who does your housework?

Was it a routine visit or for a specific reason?

Which hospital?

Who does your grocery shopping?

Who gives you your medications?

Who pays your bills?

Who does your laundry?

PLEASE CHECK ALL THAT APPLY:

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Are you bedbound? *

Do you require the use of a Walker/Cane/Crutch? (Circle which one) *

Do you need someone to assist you in the use of the wheelchair? *

Do you have control of your bowel? *

How Often?

Do you use the Toilet /Urinal/Bedpan /Commode? *

Check each that apply

Toilet
Urinal
Bedpan
Commode

Do you have a colostomy? *

Are you able to feed yourself? *

Yes
Need Assistance

Are you able to dress yourself? *

Yes
Need Assistance

Are you able to communicate well on your own? *

Yes
Need Assistance

Do you have any allergies or sensitivities to any medication? *

IF YES, which medications, and how do you react? *

Are you able to walk? *

Do you have a wheelchair? *

Do you use the wheelchair Inside / Outside? (Circle which one) *

Do you have control of your bladder? *

How Often?

Do you have a foley catheter? *

Do you have a Urostomy?

Do you have a feeding tube? *

Type?

Are you able to give yourself a bath / shower? *

Yes
Need Assistance

Are you able to groom yourself?

Yes
Need Assistance

Do you have an Emergency Lifeline? *

Please tell us about your past medical history.

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Diabetes *

Coronary Artery Disease/Angina/Chest Pain *

High Cholesterol *

Swelling of legs / ankles *

Heart valve disease (heart murmur) *

Ulcers – (Stomach/Duodenal) *

Bleeding from stomach or rectum *

Hard of hearing / Hearing aid *

Glaucoma (increased pressure in eye) *

Parkinson’s disease *

Dementia (Forgetfulness)

Lung disorders/Breathing problems *

Liver disorders / jaundice *

High Blood Pressure *

History of heart attack *

Date / Time *

Congestive heart failure *

First Choice
Second Choice

Swelling of legs / ankles *

Cardiac arrhythmia (irregular heartbeat / pacemaker) *

Pancreatitis *

Acid Reflux Disease – GERD *

Vision problems – cannot read even if using glasses *

Stroke

Treated for Depression *

Thyroid (hyper/hypo) *

Bronchitis, pneumonia (in the last few years) *

Additional Information

About IRIS

Iris Health utilizes an exceptional team of physicians, nurse practitioners, and physician assistants to provide in-home primary care to Medicare and commercial insurance customers. At Iris Health, we believe in increasing easy access to individualized, quality medical care in order to improve health. With years of experience, our medical staff will evaluate you and develop a personalized care plan that is suitable for you.

Our Services

Transition Care Management
Remote Patient Monitoring
Chronic Care Management
Advanced wound care
Telehealth Services
Mobile Services

Mobile Services

Labs
X-ray
Ultrasound
EKG
Infusion
Mobile CT & MRI Coming Soon

Iris Health Medical Group

Address : 1420 River Park Drive, Ste 120 Sacramento CA 95815

Phone: (916) 231-4747

Fax: 916.404.5556

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