Integrative Medicine Intake Form OR FAX 847-657-3521 - northshore-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your name, age, contact number, appointment date, birth date, and email address. This ensures that the clinic can reach you easily.
3. In the 'Concern' section, rank your health issues by priority. Provide details on the onset, frequency, and severity of each concern to give a clear picture of your health status.
4. Fill out your past medical history succinctly. Include dates or years of diagnosis and any relevant procedures. You may attach a separate list if needed.
5. Complete the family medical history section by indicating any diseases present in your family. This information is crucial for understanding potential hereditary conditions.
6. Detail any surgeries or injuries you've had and provide information about tobacco and alcohol use. Be honest for accurate assessment.
7. List any allergies or intolerances you have to medications or foods. Include current medications and supplements with dosages and reasons for taking them.
8. Describe your lifestyle habits such as physical activities, relaxation methods, sleep patterns, stressors, and nutrition history to provide a comprehensive view of your health.

Start filling out your Integrative Medicine Intake Form today using our platform for free!