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.
If you do not already have Adobe Reader® installed on your computer, Click here to download.
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.
F2 – Patient Personal Information-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
F14 – Behavioral Health Authorization for the Exchange of Information
Traditional Chinese Medicine