Name ___________________________________________________________________________ Date ___________________________
Rate each of the following symptoms based on how you’ve been feeling for the: Past 48 hours Past week Past 30 days
Point Scale 0 — Never or almost never have the symptoms 2 — Occasionally have it; effect is severe
1 — Occasionally have it; effect is not severe 3 — Frequently have it; effect is not severe
4 — Frequently have it; effect is severe
Head _________ Headaches
_________ Faintness
_________ Dizziness
_________ Insomnia Total ______
Eyes _________ Watery or itchy eyes
_________ Swollen, reddened or sticky eyelids
_________ Bags or dark circles under eyes
_________ Blurred or tunnel vision (does not include
near- or farsightedness) Total ______
Ears _________ Itchy ears
_________ Earaches, ear infections
_________ Drainage from ear
_________ Ringing in ears, hearing loss Total ______
Nose _________ Stuffy nose
_________ Sinus problems
_________ Hay fever
_________ Sneezing attacks
_________ Excessive mucus formation Total ______
Mouth/ _________ Chronic coughing
Throat _________ Gagging, frequent need to clear throat
_________ Sore throat, hoarseness, loss of voice
_________ Swollen or discolored tongue, gums, or lips
_________ Canker sores Total ______
Skin _________ Acne
_________ Hives, rashes, dry skin
_________ Hair loss
_________ Flushing, hot flashes
_________ Excessive sweating Total ______
Heart _________ Irregular or skipped heartbeat
_________ Rapid or pounding heartbeat
_________ Chest pain Total ______
Lungs _________ Chest congestion
_________ Asthma, bronchitis
_________ Shortness of breath
_________ Difficulty breathing Total ______
Digestive _________ Nausea, vomiting
Tract _________ Diarrhea
_________ Constipation
_________ Bloated feeling
_________ Belching, passing gas
_________ Heartburn
_________ Intestinal/stomach pain Total ______
Joints/ _________ Pain or aches in joints
Muscles _________ Arthritis
_________ Stiffness or limitation of movement
_________ Pain or aches in muscles
_________ Feeling of weakness or tiredness Total ______
Weight _________ Binge eating/drinking
_________ Craving certain foods
_________ Excessive weight
_________ Compulsive eating
_________ Water retention
_________ Underweight Total ______
Energy/ _________ Fatigue, sluggishness
Activity _________ Apathy, lethargy
_________ Hyperactivity
_________ Restlessness Total ______
Mind _________ Poor memory
_________ Confusion, poor comprehension
_________ Poor concentration
_________ Poor physical coordination
_________ Difficulty in making decisions
_________ Stuttering or stammering
_________ Slurred speech
_________ Learning disabilities Total ______
Emotions _________ Mood swings
_________ Anxiety, fear, nervousness
_________ Anger, irritability, aggressiveness
_________ Depression Total ______
Other _________ Frequent illness
_________ Frequent or urgent urination
_________ Genital itch or discharge Total ______
Grand Total __________
Metabolic Detoxification Questionnaire
What are you currently feeling?
For Practitioner Use Only:
Urinary pH _________
_________ Decreased Libido _________ Impotence
_________ Stressed
NEW PATIENT PACKET
GET RELIEF NOW
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 1/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.
Patient Name: ______________________________________________________ Weight: _____________________
Patient Email: ______________________________________________________ Height: ______________________
Phone number: ___________________________ Date: ____________________ Goal Weight: _________________
I Want Relief From:
Cardiovascular Weight Management p Heart Disease p Obesityp Hypertension p Weight Distributionp Chronic Inflammationp Peripheral Vascular Disease Neurologicalp High Cholesterol p Migrainesp Atherosclerosis p Risk of Strokep Edema p Headaches
Musculoskeletal Gastrointestinalp Fibromyalgia p Leaky Gutp Joint Pain p Fatty Liver Diseasep Risk of Autoimmune Disease p Irritable Bowel Syndrome (IBS)p Inflammatory Arthritis (Rheumatoid Arthritis) p Heart Burnp Inflammatory Arthritis (Lupus) p Crohn’s Diseasep Chronic Inflammation p Ulcerative Colitis
Pulmonary Endocrinep Shortness of Breath p Hypothyroidismp Allergies p Type 2 Diabetes
p Metabolic SyndromeMen’s Health p Adrenal Fatiguep Erectile Dysfunction p Hashimoto’s Diseasep Decreased Libidop Hormone Replacement Therapy Sleep
p SnoringWomen’s Health p Sleep Apneap Polycystic Ovary Syndromep Menopausal Symptoms Kidney p Hormone Replacement Therapy p Risk of Chronic Kidney Diseasep Infertility
Any other medical concerns that you need help with?: _________________________________________________
__________________________________________________________________________________________________
Schedule your Free, No Obligation Consultation with our INSPIRE Core Wellness Program Counselor:
Medical Wellness & Weight Loss Center
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1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 1/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.
I Would Like To: (check all that apply)
p Be Free of Pain p Be More Relaxed p Burn More Body Fat p Create a Wellness Lifestyle p Feel More Vital p Get Less Colds and Flu p Get Rid of Allergies p Have More Energy p Have More Muscle Tonep Improve Memory p Improve Sex Drive p Lose Weight p Reduce my Dependence on Medication p Reduce my Risk of Degenerative Disease p Sleep Better p Slow Down Aging Process p Think More Clearly
p Other: _________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medical Wellness & Weight Loss Center
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.com Copyright © 1/17 Heal n Cure SC. All Rights Reserved. Do not reproduce without written permission.
Patient Medical History Form
Name: Age: Sex: M F
Present Status:
1. Are you in good health at the present time to the best of your knowledge? Yes No Explain a “no” answer:
2. Are you under a doctor’s care at the present time? Yes No If yes, for what?
3. Are you taking any medications at the present time? Yes No
Prescription Drugs: List all Drug: Dosage:
Over-the-Counter medications, vitamins, supplements: List all Yes No Product Dosage
4. Any allergies to any medications? Yes No Please list:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
5. History of High Blood Pressure?
6. History of Diabetes?At what age:
7. History of Heart Attack or Chest Pain or other heart condition?
8. History of Swelling Feet
9. History of Frequent Headaches?Migraines? Yes No Medications for Headaches:
10. History of Constipation (difficulty in bowel movements, diarrhea, IBS)?
11. History of Glaucoma?
12. History of Sleep Apnea?
13. Any other medical problems?
_________________________________________________________________________________________
Yes No
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Date:
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.com Copyright © 1/17 Heal n Cure SC. All Rights Reserved. Do not reproduce without written permission.
13. Gynecologic History: Dates:Pregnancies: Number:
Natural Delivery or C-Section (specify):Complications with pregnancy (Infertility, Gestational Diabetes, Preeclampsia, High BP, Other?)__________________________________________________________________________________________Menstrual: Onset:
Duration: Are they regular: Yes No Pain associated: Yes No Last menstrual period:
Hormone Replacement Therapy: Yes No What:
Birth Control Pills: Yes No Type:
Last Check Up:
14. Serious Injuries: Yes No Specify (list all) Date
15. Any Surgery:Yes No Specify: (List all) Date
17. Family History:
Age Health Disease Cause of Death Overweight?
Father:
Mother:
Brothers:
Sisters:
Has any blood relative ever had any of the following:
Glaucoma: Yes No Who: Asthma: Yes No Who: Epilepsy: Yes No Who: High Blood Pressure Yes No Who: Kidney Disease: Yes No Who: Diabetes: Yes No Who: Psychiatric Disorder Yes No Who:
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16. Toxin Exposure: Are you exposed to (Circle applicable) Fumes / Strong odors / Gardening Farming Products
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.com Copyright © 1/17 Heal n Cure SC. All Rights Reserved. Do not reproduce without written permission.
Heart Disease/Stroke Yes No Who:
Past Medical History: (check all that apply)
Polio Measles Tonsillitis Jaundice Mumps Pleurisy Kidneys Scarlet Fever Liver Disease Lung Disease ` Whooping Cough Chicken Pox Rheumatic Fever Bleeding Disorder Nervous Breakdown Ulcers Gout Thyroid Disease Anemia Heart Valve Disorder Heart Disease Tuberculosis Gallbladder Disorder Psychiatric Illness Drug Abuse Eating Disorder Alcohol Abuse Pneumonia Malaria Typhoid Fever Cholera Cancer Blood Transfusion Arthritis Osteoporosis Other:
Nutrition Evaluation:
1. Present Weight: Height (no shoes): Desired Weight:
2. In what time frame would you like to be at your desired weight?
3. Birth Weight: Weight at 20 years of age: Weight one year ago:
4. What is the main reason for your decision to lose weight?
5. When did you begin gaining excess weight? (Give reasons, if known):
6. What has been your maximum lifetime weight (non-pregnant) and when?
7. Previous diets you have followed: Give dates and results of your weight loss:
8. Is your spouse, fiancee or partner overweight? Yes No
9. By how much is he or she overweight?
10. How often do you eat out?
11. What restaurants do you frequent?
12. How often do you eat “fast foods?”
13. Who plans meals? Cooks? Shops?
14. Do you use a shopping list? Yes No
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15. What time of day and on what day do you usually shop for groceries?
16. Food allergies:
17. Food dislikes:
18. Food(s) you crave:
19. Any specific time of the day or month do you crave food?
20. Do you drink coffee or tea? Yes No How much daily?
21. Do you drink soda/juice/flavored water? Yes No How much daily?
22. Do you drink alcohol? Yes No
What? How much daily? Weekly?
23. Do you use a sugar substitute? Butter? Margarine?
24. Do you awaken hungry during the night? Yes No
What do you do?
25. What are your worst food habits?
26. Snack Habits:
What? How much? When?
27. When you are under a stressful situation at work or family related, do you tend to eat more? Explain:
28. Do you thing you are currently undergoing a stressful situation or an emotional upset? Explain:
29. Smoking Habits: (answer only one)
You have never smoked cigarettes, cigars or a pipe. You quit smoking years ago and have not smoked since. You have quit smoking cigarettes at least one year ago and now smoke cigars or a pipe without inhaling smoke. You smoke 20 cigarettes per day (1 pack). You smoke 30 cigarettes per day (1-1/2 packs).
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.com Copyright © 1/17 Heal n Cure SC. All Rights Reserved. Do not reproduce without written permission.
5
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.com Copyright © 1/17 Heal n Cure SC. All Rights Reserved. Do not reproduce without written permission.
You smoke 40 cigarettes per day (2 packs).
30. Typical Breakfast Typical Lunch Typical Dinner
Time eaten: Time eaten: Time eaten: Where: Where: Where: With whom: With whom: With whom:
31. Describe your usual energy level:
32. Activity Level: (answer only one) Inactiveno regular physical activity with a sit-down job. Light activityno organized physical activity during leisure time. Moderate activityoccasionally involved in activities such as weekend golf, tennis, jogging,
swimming or cycling. ____Heavy activityconsistent lifting, stair climbing, heavy construction, etc., or regular participation in
jogging, swimming, cycling or active sports at least three times per week.. Vigorous activityparticipation in extensive physical exercise for at least 60 minutes per session 4 times per week.
33. Behavior style: (answer only one) You are always calm and easygoing. You are usually calm and easygoing. You are sometimes calm with frequent impatience. You are seldom calm and persistently driving for advancement. You are never calm and have overwhelming ambition. You are hard-driving and can never relax.
34. Please describe your general health goals and improvements you wish to make:
This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form.
6
It is your responsibility to know if your insurance has specific rules or regulations, such as the need for refer-rals, recertification’s, preauthorization’s, limits on outpatient charges, specific physicians and/or hospitals to use. You should be knowledgeable of any deductibles, copayments, and/or coinsurance. This applies to all payers regardless of whether or not our physicians participate.
The responsibility for payment of fees for services is your direct responsibility. Your health benefit plan is an arrangement between you, the enrollee, and the insurance company or your employer. We will do our best to assist you with understanding your proposed treatment and in answering questions related to your insurance.
We require you to provide us with 24 hour notice for prescription refill during the weekday. The requests made over the weekends and holidays will be filled the following business day. We need minimum of five day notice to fill out any paperwork.
Should you have any questions with regard to our financial policy we encourage you to ask.
We ask that you present the correct and updated contact and medical insurance information at the time of each visit. Please notify the receptionist of any changes during the subsequent visits promptly.
The office requires at least 24 hours’ notice when canceling an appointment. Failure to provide this notice will result in a charge of up to $75.00
No refunds are allowed under any circumstances.
Individual results vary. There are no guaranteed results.
Fee per current Illinois State Auditor guidelines (Minimum $25.00)
Accounts are sent to collection 60 days after the due date. This results in an automatic termination from the practice. A 25% collection fee and 10% annual interest is added to the amount due.
Payment Policy Schedule*
Full payment due at time of service
Other charges/fees* Full payment due at time of service
* subject to change at any time
No refunds or guarantees
FINANCIAL POLICY
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 1/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.
Medical Wellness & Weight Loss Center
☐ Copayments ☐ Deductible and coinsurance
☐ Non-covered service ☐ Nonparticipating insurance plan
☐ Return Check Fee $25.00
☐ Cancellation/ MissedAppointment Fee
☐ I have read and I understand the Heal n Cure Financial Policy.
☐ I have received the list of likely billing codes and have verified that my insurance company will coveror I will pay for the same if it is not covered by insurance.
☐ No refunds
☐ No guarantees
☐ Medical Records
☐ Collection Charges
______________________________________ Patient Signature
______________________________________ Date
Wellness Weight Loss Family Medicinel l
Please check all boxes below to acknowledge you have read the financial policy
7
PATIENT REGISTRATION
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 1/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.
Last Name: ____________________________ First Name:___________________________________ MI: ________
Address: _____________________________ City, State, Zip: _____________________________________________
Home #:( ) ____________________ Work #:( ) ___________________ Cell #:( ) ___________________
Circle your preferred method: phone , email , text , voice mail
Social Security #: __________________ Date of Birth: ____________________ Age: _________________________
Gender: M F Marital Status: __________________ Email: _____________________________________________
How did you hear about our practice? ______________________________________________________________
Would you like to subscribe to our newsletter? Yes ___ No ___
I have come to Heal n Cure based upon my interest in (mark all that apply):
INSPIRE (medically supervised weight loss program) ___ BLISS (lipo-laser treatment) ___
LUSTRE (aesthetic laser treatment) ___
*Complimentary Consults with Lifestyle Educators are available for additional information about our programs.
Employment Information:
Employer: ____________________________________________ Occupation: _______________________________
Address: _____________________________ City, State, Zip: _____________________________________________
Phone #:( ) ____________________
Emergency Contact :
Name: _________________________________ Relation: ______________ Phone #:( ) ____________________
Secondary Emergency Contact :
Name: _________________________________ Relation: ______________ Phone #:( ) ____________________
Primary Care Provider (PCP):
PCP Doctor: ______________________________________________________________________
Address: _____________________________ City, State, Zip: _____________________________________________
Phone #:( ) ____________________ Fax #:( ) ____________________
Office Use NPI: _____________________________
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PATIENT REGISTRATION
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 1/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.
I, ______________________, give consent to Heal n Cure to
access my previous prescriptions.
Print Name: ____________________________
Signature: ______________________ Date:______________
Booking Future Appointments:
For our patient’s convenience, booking, rescheduling and managing your next appointment with Heal n
Cure can be accomplished in person at our office, by phone (847)-686-4444, or online through our
uBook feature at www.healncure.com.
Statement of Acknowledgement:
I certify that information provided is true and accurate. I understand and agree that, regardless of my insur-
ance status, I am ultimately responsible for the balance of my account. I authorize payment of medical ben-
efits to Heal n Cure when assignment has been taken. I have read the office financial policy and agree to all
terms and conditions. I authorize Heal n Cure to use or disclose any information for treatment, payment, and
healthcare operations. I authorize that the physicians and/or employees of Heal n Cure can contact me via
all necessary means (phone, email, fax, etc) or leave me a message if they are unable to contact me directly.
I acknowledge that I have received a copy of the Notice of Privacy Practices.
Signature ______________________________________________________________ Date: ___________________
Preferred Pharmacy: Name, address, phone/fax
_____________________________________________________________________________________________________________________________________________________________________________________________________________________PRESCRIPTION HISTORY CONSENT
9
Heal n Cure, SC Meena Malhotra, MDwww.healncure.com Phone: 847-686-4444
Fax: 847-686-9999
Acknowledgement Of HIPAA Laws
I_________________________, herby acknowledge the receipt and complete understanding of Notice Of Privacy Practices of Heal n Cure, SC which provides detailed information about how the practice may use and disclose my confidential information.
I understand that Heal n Cure has reserved the rights to change its privacy practices that are described in the Notice. I also understand that a copy of any revised notice will be provided to me or made available at the subsequent visit to the clinic.
Signature: _____________________________ Date: ________________
If you are not the patient, please verify your relationship to the patient.
Relationship to Patient:___________________
Signature: _____________________________ Date: ________________
1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.com Copyright © 2016 Heal n Cure SC. All Rights Reserved. Do not reproduce without written permission.
10
Revised 01/17
Patient Name: Patient DOB: Patient MRN:
Date :
Depression Screening and Management GuidelineScreen every 2 years for chronic illness or wellness patients No Yes During the past two weeks, have you ever felt down, depressed or hopeless? During the past two weeks, have you felt a lack of pleasure or interest in doing things?
YES (to both) – Answer the following DSM IV Criteria: No Yes NO (to both) 1. Depressed mood most of the day, nearly every day Re-screen at 3 and 6 months 2. Markedly diminished interest or pleasure in almost all activities
most of the day, nearly every dayfor post-MI and every 2 years for all
others 3. Significant weight loss or weight gain4. Insomnia / hypersomnia5. Psychomotor agitation / retardation6. Fatigue (loss of energy)7. Feelings of worthlessness (guilt)8. Impaired concentration (indecisiveness)9. Recurrent thoughts of death or suicide
No Yes IS THERE A DOMINANT SECONDARY ETIOLOGY? (e.g., meds / thyroid abnormality)
Treat
IS THERE ASSOCIATED PSYCHOSIS OR MANIA?
IS THERE SUICIDAL IDEATION? (send to emergency room if acutely suicidal)
TREAT WITH HEART SAFE SSRI: SERTRALINE: mg Treat and/or CITALOPRAM: mg Consider
OTHER: mg Behavioral Health Referral
REASSESSMENT AT 6 WEEKS SHOWS IMPROVEMENT?
WOULD LIKE 2ND OPINION / RECOMMEND PSYCHOTHERAPY?
BEHAVIORAL HEALTH RESOURCE NETWORK Direct Referral for Non-Urgent Care: HMOI/BA : 800-346-3986 Blue Medicare Advantage: 800-753-5456
Aetna: 800-342-5840 or ID Card Cigna: 800-541-7526 or ID Card Humana: 800-331-9040 Unicare: 800-746-6294
Heal n Cure Wellness. Weight Loss. Family Medicine
Patient Name: Chart Number: - - - - - - - - - - - - - - -- - - - - - - - - - - -
The following questions ask about your eating patterns and
behaviors within the last 3 months. For each question, choose
the answer that best applies to you.
1. During the last 3 months, did you have any episodes of
excessive overeating (i.e., eating significantly more than
what most people would eat in a similar period of time)?
Yes
NOTE: IF YOU ANSWERED "NO" TO QUESTION 1, YOU MAY STOP.
THE REMAINING QUESTIONS DO NOT APPLY TO YOU.
2. Do you feel distressed about your episodes
of excessive overeating?
Within the past 3 months ...
3. During your episodes of excessive
overeating, how often did you feel like
you had no control over your eating (e.g.,
not being able to stop eating, feel
compelled to eat, or going back and
forth for more food)?
4. During your episodes of excessive
overeating, how often did you continue
eating even though you were not hungry?
5. During your episodes of excessive
overeating, how often were you
embarrassed by how much you ate?
6. During your episodes of excessive
overeating, how often did you feel
disgusted with yourself or guilty afterward?
7. During the last 3 months, how often
did you make yourself vomit as a means
to control your weight or shape?
Never
or Sometimes
Rarely
This information is brought to you by Shire US Inc.
Yes
Often
No
No
Always
1122 Willow Road I Northbrook, IL 600621 Tel 847.686.44441 Fax 847.686.99991 www.healncure.com Copyright© 1/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.
Date: ___________________________
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