First Health Associates offers online forms for your convenience.  The list below includes all necessary new patient forms that can be competed in convenience of your home or office.

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Download the necessary form(s), print them out and fill in the required information.
Fax us your completed form(s) or bring them with you to your appointment.  Fax 847-593-3346.

New Patient Forms
Please complete forms 1-4 PLUS the intake forms listed under the type of provider you will be seeing.  If you cannot complete the forms prior to your visit, please arrive 30 minutes before your scheduled new patient appointment to complete them in our office.

1 – Medical History

F2 – New Patient Demographics

F3 – New Patient Consent To Treat

F4 – New Patient Office Financial Policy

* * * Additional Provider Specialty Intake Forms

 

Physical Medicine & Rehab

F5 – Physical Medicine and Rehabilitation Musculoskeletal Intake Form

F6 – Physical Medicine and Rehabilitation Headache Disability Index

Chiropractic

F7 – Chiropractic New Problem Intake

F8 – Chiropractic Follow Up Re-Exam

F9 – Chiropractic Neck or Back Functional Rating

F10 – Chiropractic Lower Extremity Functional Rating

F11 – Chiropractic Upper Extremity Functional Rating

Behavioral Health

F12 – Behavioral Health Self-Reporting Check List

F13 – Behavioral Health Informed Consent HIPAA Transfer Plan

F14Behavioral Health Authorization for the Exchange of Information

Traditional Chinese Medicine

F15 – Traditional Chinese Medicine Patient History Intake