Summer Salad
Summer Salad

This colorful summer salad delivers a wonderful flavor combination and serves as a perfect side

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Fish Kabobs
Fish Kabobs

White fish kabobs and vegetables. Print Fish Kabobs Fish Kabobs with Vegetables Ingredients1 lb firm

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Lentil Salad
Lentil Salad

“This is a delicious lentil salad, that keeps very well in the refrigerator.” Print Lentil

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Lentil Salad
Lentil Salad

Lentils are actually quite delicious and surprisingly nutritious.  So, for today’s post, I thought I’d

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edamame-dip
Edamame Dip

Edamame (eh-dah-MAH-may) are nothing more than fresh soy beans. Typically cooked in heavily salted water,

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Medication Histroy

Your Wellness Journey Starts here.
  • Please check any of the following medications you have taken in the past or are currently taking.
  • Date Format: MM slash DD slash YYYY

Metabolic Detoxification Questionnaire

Your Wellness Journey Starts here.
  • Point Scale
    • 0 - Never or Almost never have the symptoms
    • 1 - Occasionally have it, effect is not severe
    • 2 - Occasionally have it, effect is severe
    • 3 - Frequently have it, effect is not severe
    • 4 - Frequently have it, effect is severe
      • Date Format: MM slash DD slash YYYY
      • Head

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Eyes

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Ears

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Nose

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Mouth / Throat

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Skin

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Heart

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Lungs

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Digestive Tract

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Joints/ Muscles

      • Weight

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Energy/ Activity

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Mind

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Emotions

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Other

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.

Neurotransmitter Assessment Form

Your Wellness Journey Starts here.
  • Date Format: MM slash DD slash YYYY
  • SECTION A

    Select any one option on a scale : 0 being Never to 3 being Always
  • SECTION B

  • SECTION C

    Section C1
  • Section C2
  • SECTION D

  • SECTION E

  • SECTION F

  • SECTION G

Financial Policy Consent

  • FINANCIAL POLICY

  • It is your responsibility to know if your insurance has specific rules or regulations,such as the need for referrals,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.

    Please check all boxes below to acknowledge you have read the financial policy
  • Payment Policy Schedule


  • Other charges/fees*

  • *subject to change at any time


  • 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.
  • Date Format: MM slash DD slash YYYY

Hormone Deficiency Assessme

Your Wellness Journey Starts here.
  • Date Format: MM slash DD slash YYYY
  • Fill up the details promptly below so as to analyze if you need any treatment related to hormone deficiency.
  • TESTOSTERONE

  • Signs and symptoms ( Men and Women )
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • Signs and symptoms ( Men Only )
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • Score for Women: [5 or less : Satisfactory level] [6-10 : Possible Testosterone deficiency] [11 or more : Probable Testorsterone deficiency ] Score for Men: [ 10 or less: Satisfactory level ] [ 11 to 20 : Possible Testorsterone deficiency ] [ 21 or more : Probable Testorsterone deficiency ]
  • ESTROGEN

  • Signs and symptoms
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : (0=moderate I 1-3=1ow / 4=none)
    Select any one option on a scale : (<27 days),or too long (>31 days)
    Select any one option on a scale : 0 being Never to 4 being Always
  • The overall total of 10 or less is satisfactory level. Between 11-20: Possible Estrogen deficiency. 21 or more: Probable Estrogen deficiency.
  • PROGESTERONE

  • Signs and symptoms
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • [The following questions are for women who have not yet reached menopause, and menopausal women who are taking hormone replacement therapy (estrogen or estrogen and progesterone).]
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • Post-menopausal women not treated with hormone replacement therapy (estrogen or estrogen and progesterone): 4 or less: Satisfactory level. Between 5 and 8: Possible Progesterone deficiency. 9 or more: Probable Progesterone deficiency ------- Menstrual women and menopausal women taking hormone replacement therapy (estrogen or estrogen and progesterone): 10 or less: Satisfactory level. Between 11 and 20: Possible Progesterone deficiency. 21 or more: Probable Progesterone deficiency
  • THYROID

  • Signs and symptoms
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • The overall total is 10 or less is satisfactory level. Between 11-20: Possible Thyroid Hormone deficiency. 21 or more: Probable Thyroid Hormone deficiency.
  • DHEA

  • Signs and Symptoms ( Men and Women )
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    (0 = plenty of hair/ 4 = hairless)
    (flat "mound ofVenus" in women). (0 = padded/4 = flat)
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • The overall total is 10 or less is satisfactory level. Between 11-20: Possible DHEA deficiency. 21 or more: Probable DHEA deficiency

Impact of Medical Conditions

  • Impact of Medical Conditions on Your Life

  • Date Format: MM slash DD slash YYYY
  • How does this problem interfere with the following areas in your life?

  • Rate on a scale of 1-10

Patient Registration


  • Employment Information:


  • Emergency Contact :



  • Secondary Emergency Contact :



  • Primary Care Provider (PCP) :


Get Relief Now

  • Date Format: MM slash DD slash YYYY
    ( Check all that apply )

HIPAA Consent

  • Heal n Cure, SC www.healncure.com
    Meena Malhotra, MD Phone: 847-686-4444 Fax: 847-686-9999
  • I hereby 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.
  • Date Format: MM slash DD slash YYYY
  • If you are not the Patient, please verify your relationship to the patient.

  • Date Format: MM slash DD slash YYYY