755 Ela Road Lake Zurich IL

(847) 550-9784

Please click on the title below to access the forms listed based on your insurance and fill out prior to your first visit. If you do not fill out forms prior to your visit, please arrive 15 minutes prior to your scheduled appointment to them out in the clinic.  Please also bring the prescription from your referring physician.

Medicare Patients

Patient Intake Form
Medical History Form
Medication List
Falls Risk Checklist
Patient Consent Form
Patient Cancellation Policy
Visual Pain Scale/Body Map

Non-Medicare Patients

Patient Intake Form
Medical History Form
Patient Consent Form
Patient Cancellation Policy
Visual Pain Scale/Body Map

Required Pelvic Forms

For those who primary complaint involves: Bowel, Bladder or Prolapse: fill out Bowel, Bladder, Prolapse Questionnaire (PFDI 20)

Females whose primary complaint is pain: Female Pain Questionnaire (Female NIH)

Males whose primary complaint is pain:  Male Pain Questionnaire: (Male NIH)