Home Patient Services Patient Forms and Medical Record Request Patient Forms - Integrative Medicine

Patient Forms - Integrative Medicine

Personal and Family Health History Form:

Please print out the Personal and Family Health History

Chiropractice Medical History Form

Please fill in the Medical History Form online, print it out, and then bring it with you.

Nutrition Consultation Form

Before your first appointment with Judy Fulop, M.S., N.D. the Nutrition Consultation Form is to be completed and received in our office 24 hours prior to your consultation. You can use one of these methods:

Fax the form to our office: (312) 926-6285
Mail the form to our office:

Dietitian Consultation Form

Before your first appointment with our dietitian, please fill out the Nutrition Therapy Introductory Questionnaire, and then bring it with you.

How to Request Medical Records:

Click the office you visit for the appropriate Medical Records form Print and fill out the Release of Information (ROI) Form. You may submit your request:

Via fax to 312-926-3093 (Attention: Health Information Management)
Via mail to Health Information Management, 541 N Fairbanks, Suite 1475, Chicago, IL 60611
In-person at the office you visit. If you need to speak to a NMPG representative about the status of your request please call 312-926-3627 (DOCS)

Click on the office you visit for the Medical Records Form:

Northwestern Integrative Medicine