Get Il Northshore University Healthsystem Integrative Medicine Intake Form 2015-2025

Completing the IL NorthShore University HealthSystem Integrative Medicine Intake Form online is an essential step in preparing for your visit. This guide provides clear, step-by-step instructions to help you navigate the form effectively and ensure all necessary information is submitted accurately.

Follow the steps to complete the form online with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in your personal information at the top of the form. This includes your name, age, contact number, appointment date, birth date, and email address. Please make sure all information is accurate.
3. In the section labeled 'How were you referred to our center?', indicate the source of your referral, such as a healthcare provider or a friend.
4. Under 'Concern', list your health concerns in order of priority, providing details about each concern.
5. For the 'Onset' section, specify when each concern started and how often it occurs.
6. Indicate the 'Severity' of each concern on a scale according to the provided examples.
7. State your goals for the visit in the designated section to help your healthcare provider understand what you wish to achieve.
8. Fill out your past medical history, noting conditions and procedures along with their dates.
9. Provide information about your family medical history, including any significant diseases.
10. Detail any surgeries, major or minor, and their dates, as well as any past injuries.
11. Indicate your tobacco use if any, followed by additional details about alcohol and recreational drug use.
12. List any known allergic reactions or intolerances to medications, foods, or environmental factors.
13. Document any medications you are currently taking, including dosages, frequency, reasons, and costs if applicable.
14. Include any herbs, vitamins, and supplements you take, following the same format as the medications.
15. Describe your occupation, living situation, and the individuals you reside with.
16. Share your physical activity routines, gym membership status, and hobbies.
17. Provide details about your sleep patterns and major stressors in your life.
18. Discuss any spiritual or religious practices you may have, along with experiences with complementary and alternative medicine.
19. Answer questions regarding your nutrition history, including daily fruit and vegetable servings.
20. At the end of the form, ensure all information is complete before saving your changes. You can download, print, or share the completed form as needed.

Complete your forms online to ensure a smooth appointment process.