George J. Lubertazzo, DC
39 Meadow Road
P.O. Box 1727
Rutherford, NJ 07070
201-896-0068

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

Welcome to our office of chiropractic. Thank you for taking a moment to fill in our Patient Intake Form. Please fill this form completely and to the best of your knowledge. Let our staff know if you have any questions. When complete return it to our office with the bottom authorization checked and appropriate signatures filled in.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information

Contact Information

*First Name:
Middle Name:
*Last Name:
*Gender:	Female Male
*Date of Birth:
Social Security #:
Height:	Feet Inches
Weight:
Marital Status:
Spouse's Name:
Number of Children:

Emergency Contact:
Relationship:
Phone:

*Email:
	(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)
*Home Phone:
Cell Phone:
Work Phone:

Country:
Address Line 1:
Address Line 2:
City:
State/Province/Region:
*Zip/Postal Code:

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Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms

How did you find out about our office?

Referring Physician:
Referring Patient:
Referred by:

Did you hear about our office from an advertisement?

No Yes

If Yes, Where:

Did you hear about our office from a phone or professional directory?

No Yes

If Yes, Where:

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Employment Information

Regular Work Status:
Employer Name:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Occupation:
Supervisor Name:
Supervisor Phone/Extension:
Physical Work Duties:

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What is the purpose of your visit?

Wellness Complaint Injury Other

Current Symptoms

Where did the injury occur?

Automobile Work 3rd Party Premises Other

Date of Injury:

Please Describe how the injury, pain, or discomfort originated:

Please describe your pain/discomfort:

Select frequency you experience pain from this condition:

Always Hourly Daily Occasionally

Does this condition interfere with any of your daily activities or routines?

No Yes

Has this condition affected your quality of sleep or ability to sleep?

No Yes

Has this condition affected your appetite?

No Yes

If Yes, Explain:

Have you missed any work due to this injury?

No Yes

If yes:
Select unable to work from date:
Select day you have or will return to work:

Have you reduced or limited your work hours because of this condition?

No Yes

If Yes, Explain:

Is the pain/discomfort worse at certain times of the day?

No Yes

If Yes, Explain:

Does the weather affect your pain/discomfort?

No Yes

If Yes, Explain:

List anything that aggravates your condition:

List anything that relieves or improves your condition:

Have you received professional treatment for this condition?

No Yes

If Yes, Explain:

Have you had X-rays taken for this condition?

No Yes

If Yes, Where?

Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best: At its Worst: Current Level:

Have you ever had this same condition?

No Yes

If Yes, When?:

List other practitioners seen for this injury/condition:

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Insurance & Payment for Care

How do you plan to pay for care?

Personal Insurance Third-Party Insurance No Insurance, Self-Pay

Name of Party Responsible for Payment:
Responsible Party Phone:

Primary Insurance

Secondary Insurance

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

If an auto accident, please provide:

Claim #:
Insurance Contact Person:
Insurance Phone:
Attorney's Full Name:
Attorney's Phone:

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Personal Health History

Family/Primary Physician

Date of Last Physical Exam:
Name of Family Physician or Physician Seen:
Physician Phone:
Physician City:
Physician State:
Physician Zip:

Please list any health conditions that you have been treated for in the last year:
(condition, cause, current/resolved)

Separate details with "," comma as shown above.

Have you had previous chiropractic care?

No Yes

Condition(s) treated:

Date of last chiropractic visit:

Are you pregnant, or have you had any signs of pregnancy? (Female Only)

No Yes

Are you planning to get pregnant in the next 12 months? (Female Only)

No Yes

List current medications:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

List current vitamins, minerals, supplements, or herbs:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

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Personal Incident History:

Broken Bones?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Had Major Sprains/Strains?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Hospitalized?

No Yes

Briefly Explain:

Had Surgery?

No Yes

Briefly Explain:

Been In Auto Accident?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Struck Unconscious?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Diagnosed with an Eating Disorder?

No Yes

Briefly Explain:

Had a Stroke?

No Yes

Briefly Explain:

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Social History & Life Choices:

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Chiropractic Experience

Who referred you to our office?

Where did you hear about us?…

Please select all that apply.

Newspaper Sign Yellow Pages Community Event Mailing Other

Other:

Have you been adjusted by a chiropractor before?

Yes No

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Has any member of your family ever seen a wellness chiropractor?

Yes No

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Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

I want the Doctor to select the type of care appropriate for my condition.

Relief care: Symptomatic relief of pain or discomfort.
Corrective care: Correcting and relieving the cause of the problem as well as the symptom.
Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

Were You Aware That...

Doctors of Chiropractic work with the nervous system?

No Yes

The nervous system controls all bodily functions and systems?

No Yes

Chiropractic is the largest natural healing profession in the world?

No Yes

Authorization

I. CONSENT: I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.If any outstanding balance is overdue more than 30 days after I suspend or terminate my care, a finance charge of 18% will be added to overdue balance. If there is a credit card on file with the office, I authorize, by signing below, the use of the credit card for payment for any outstanding balance. --------------------------------------------- II. ASSIGNMENT OF BENEFITS I hereby instruct and direct my insurance company to pay by check made out mailed to this clinic the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered by this clinic. A photocopy of this assignment shall be considered as effective and valid as the original. ------------- III. RELEASE OF INFORMATION I authorize this clinic to release any information pertinent to my case to any insurance company, adjuster, and attorney involved in this case; and hereby release the clinic of any consequence thereof. ------------------------------------------------------------------------------------------------------------------ IV. ACKNOWLEDGMENT OF RECEIPT OF NOTICE As required by the Privacy Regulations of HIPAA, I hereby acknowledge that I have read a current copy of Dr. George J. Lubertazzo, DC Family Chiropractic s Notice of Privacy Practices as posted in the office, revised April, 2020. As required by the Privacy Regulations, the office manager of Dr. Lubertazzo s office was made available to explainthe Notice of Privacy Practices as posted in the office to my satisfaction. As required by said regulations, I am aware that Dr. Lubertazzo has included a provision that reserves the right to change the terms of this notice and to make the new notice s provisions effective for all protected health information that it maintains.Good faith effort to obtain receipt: Patient declined to sign the ACKNOWLEDGMENT of receipt of notice but was made aware of the Notice of Privacy Practice as posted in the reception of the office.

* I agree with this statement of authorization

Name of the Insured: (Please Print)	_____________________________________________
Patient's/Guardian's signature:	_____________________________________________	Date:	__________

Signature

Finalizing Form

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Service provided by:

Alcohol Daily Weekly Occasionally Never	Caffeine Drinks & Products Daily Weekly Occasionally Never
Diet Food Products Daily Weekly Occasionally Never	Drugs Daily Weekly Occasionally Never
Energy Products or Over-the-Counter Stimulants Daily Weekly Occasionally Never	Exercise Daily Weekly Occasionally Never
Fresh & Homemade Foods Daily Weekly Occasionally Never	Preprocessed, Packaged, & Restaurant Food Daily Weekly Occasionally Never
Soft Drinks Daily Weekly Occasionally Never	Tobacco Daily Weekly Occasionally Never
Water Daily Weekly Occasionally Never