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Integrated Health and Fitness Clinic
Arlington Heights
Call Us 847-873-0032
Clinical Forms
New Patient Administrative
A.
Confidential Health Information Questionnaire
E.
Consent to Email,
Text & Voicemail
B.
General
Medical History
F.
Financial Policy
C.
Integrative Health Policy & Consent to Care Agreement
D.
Hippa Privacy Policy, Treatment Consent, Claims Processing Consent
Functional Medicine
1.
Functional
Medicine
2.
Neurotransmitter Assessment Form (NTAF)
3.
Metabolic
Assessment
4.
Understanding
Our Goals
Chiropractic
1.
Patient Health Questionnaire – PHQ
5.
Functional Rating Upper Extremity
2.
Patient Follow-up Questionnaire
3.
Functional Rating Neck and Back Index
4.
Functional Rating Lower Extremity
Acupuncture
1.
New Patient Intake
Massage
2.
New Patient Intake
1.
Terms & Waiver
Misc.
1.
Release of
Medical Records