Functional Medicine Intake Forms

Your intake form is one of the most important aspects of your care and program. Please take your time carefully filling out the form and follow the instructions below carefully:

Both the Intake Form and Consent Form must be filled out and saved in Adobe or printed and filled out manually. DO NOT fill it out in your browser.

Take your time telling your story. The more we know, the better we can help. If you are not sure how to answer, leave a question mark next to the question.

Please fill this paperwork out completely. Do not leave any section blank. This paperwork is part of your exam. If the paperwork is not completely filled out at the time of your appointment you will have to reschedule.

You may send the filled out form to once completed or bring it to your consultation.

Please click on the red buttons below to download the forms.

Functional Medicine Forms

Who We Are

Welcome to Chicago Natural Health Care, located in the heart of Chicago, where we use a modern, research-based approach to manage and help people optimize their health. 




3432 W Diversey, Suite 253

Chicago, IL 60647


The information on this site is solely for purposes of general patient education, and may not be relied upon as a substitute for professional medical care. Consult your own physician for evaluation and treatment of your specific condition. Chicago Natural Health Care is in close proximity to Chicagoland's surrounding cities and areas that include Chicago, Oak Park, Des Plaines, Schaumburg, Naperville, Wilmette, Winnetka, Glencoe, Northfield, Highland Park, River North, Gold Coast, Lakeview, Old Town, Edgewater, West Loop,  Lincoln Park, Streeterville, Evanston, Bucktown, West Town, and Wicker Park. | Chicago Natural Health Care | Chicago, IL

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