new patient packet metabolic detoxiﬁcation questionnairein what time frame would you like to be at...

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

1


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: _________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________


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

2

Date:


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:

3

16. Toxin Exposure: Are you exposed to (Circle applicable) Fumes / Strong odors / Gardening Farming Products


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

4

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).


5


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



☐ 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


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: _______________________________


Phone #:( ) ____________________

Emergency Contact :

Name: _________________________________ Relation: ______________ Phone #:( ) ____________________

Secondary Emergency Contact :

Name: _________________________________ Relation: ______________ Phone #:( ) ____________________

Primary Care Provider (PCP):

PCP Doctor: ______________________________________________________________________


Phone #:( ) ____________________ Fax #:( ) ____________________

Office Use NPI: _____________________________

8

PATIENT REGISTRATION


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

http://www.healncure.com/

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)?


overeating, how often did you continue

eating even though you were not hungry?


overeating, how often were you

embarrassed by how much you ate?


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: ___________________________

12

new patient packet metabolic detoxiﬁcation questionnairein what time frame would you like to be at...

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