Dr. Tricia Mastropietro 1114 Raritan Road Suite 4

Chiropractor Clark, NJ 07066

732-388-3828

928 Broadway Suite 705

New York, NY 10010

917-922-4042

Chiropractic Patient Intake Form

Name______Sex M F Date______

Address______Apt.______State______City______Zip______

Date of Birth ______Age______Social Security#______

Insurance Company ______ID Number______

Name of Insured______Relationship to Patient______

Home Phone ______Work Phone______Cell Phone ______

Email______Best method to contact you? ______

Best time to contact you? ______Referred by ______

Occupation______Employer______

Marital status: Single MarriedDivorcedWidowedPartnered

#/gender of children______

Spouse/Partner Name______Phone Number______

Emergency Contact Name______Relationship______Phone Number______

Have you ever received Chiropractic Care?YesNo

Who? ______

When/ how long? ______

Where? ______

To the best of your ability, explain what kind of treatment you received:

______

______

Primary Physician ______

Address______

Phone______

Height _____ft._____in Weight______Lbs Dominant Hand R L Glasses/Contacts Y N

____

Chief Complaints

  1. Primary Complaint:

______

  1. Primary Complaint:

______

Complaint began when and how? ______

Is this a result of a work related injury or auto accident?______

Quality of the complaint/pain: dull aching sharp shooting burning throbbing deep nagging other ______

Does this complaint/pain radiate or travel (shoot) to any areas of your body? Where? ______

Do you have any numbness or tingling in your body? Where? ______

Grade Intensity/Severity (No complaint/pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst possible pain/complaint imaginable)

Frequency of complaint/ % of day? ______

Is the complaint worse at any particular time of day? ______

Does anything aggravate the complaint? ______

Does anything make the complaint better? ______

Previous interventions, treatments, medications, surgery, or care you’ve sought for your complaint:______

______

______

  1. SecondaryComplaint:

______

Complaint began when and how? ______

Is this a result of a work related injury or auto accident?______

Quality of the complaint/pain: dull aching sharp shooting burning throbbing deep nagging other ______

Does this complaint/pain radiate or travel (shoot) to any areas of your body? Where? ______

Do you have any numbness or tingling in your body? Where? ______

Grade Intensity/Severity (No complaint/pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst possible pain/complaint imaginable)

Frequency of complaint/ % of day? ______

Is the complaint worse at any particular time of day? ______

Does anything aggravate the complaint? ______

Does anything make the complaint better? ______

Previous interventions, treatments, medications, surgery, or care you’ve sought for your complaint: ______

______

  1. Tertiary Complaint:

______

Complaint Began when and how? ______

Is this a result of a work related injury or auto accident?______

Quality of the complaint/pain: dull aching sharp shooting burning throbbing deep nagging other ______

Does this complaint/pain radiate or travel (shoot) to any areas of your body? Where?______

Do you have any numbness or tingling in your body? Where? ______

Grade Intensity/Severity (No complaint/pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst possible pain/complaint imaginable)

Frequency of complaint/ % of day? ______

Is the complaint worse at any particular time of day? ______

Does anything aggravate the complaint? ______

Does anything make the complaint better? ______

Previous interventions, treatments, medications, surgery, or care you’ve sought for your complaint: ______

______

______

Personal Health History

Check only those conditions which are applicable:

AIDS/HIV

Alcoholism

Allergy Shots

Anemia

Anorexia

Arthritis

Asthma

Bleeding Disorders

Breast Lump

Bronchitis

Bulimia

Cancer

Chemical Dependency

Chicken Pox

Depression

Diabetes

Emphysema

Epilepsy

Fractures

Glaucoma

Goiter

Gonorrhea

Gout

Headaches

Heart Disease

Hepatitis

Hernia

Herniated Disc

Herpes

High Cholesterol

Kidney Disease

Liver Disease

Measles

Metal Implantations

Migraine Headaches

Miscarriage

Mononucleosis

Multiple Sclerosis

Mumps

Osteoporosis

Pacemaker

Parkinson’s Disease

Pinched Nerve

Pneumonia

Polio

Prostate Problems

Prosthesis

Psychiatric Care

Raynaud’s Disease/Phenomenon

Rheumatoid Arthritis

Rheumatic Fever

Scarlet Fever

Stroke

Suicide Attempt

Surgical Implantations

Thyroid Problems

Tonsillitis

Tuberculosis

Tumors, Growths

Typhoid Fever

Ulcers

Vaginal Infections

Venereal Disease

Other______

Broken Bones

Location______Date: ______

Location______Date: ______

Location: ______Date: ______

Allergies ______

Medications/Supplements

Medication/SupplementReason for taking

______

______

______

Surgery/Injury/Trauma

Date Type of Surgery/Injury/Trauma

______

______

______

Females/ Pregnancies and outcomes:

Are you currently pregnant?YesNo

Have you ever been pregnant? YesNo

Pregnancies/Date of DeliveryOutcome

______

______

______

Family Health History

Parents, Grandparents, Siblings

Check only those conditions which are applicable:

AIDS/HIV

Alcoholism

Allergy Shots

Anemia

Anorexia

Arthritis

Asthma

Bleeding Disorders

Breast Lump

Bronchitis

Bulimia

Cancer

Chemical Dependency

Chicken Pox

Depression

Diabetes

Emphysema

Epilepsy

Fractures

Glaucoma

Goiter

Gonorrhea

Gout

Headaches

Heart Disease

Hepatitis

Hernia

Herniated Disc

Herpes

High Cholesterol

Kidney Disease

Liver Disease

Measles

Metal Implantations

Migraine Headaches

Miscarriage

Mononucleosis

Multiple Sclerosis

Mumps

Osteoporosis

Pacemaker

Parkinson’s Disease

Pinched Nerve

Pneumonia

Polio

Prostate Problems

Prosthesis

Psychiatric Care

Raynaud’s Disease/Phenomenon

Rheumatoid Arthritis

Rheumatic Fever

Scarlet Fever

Stroke

Suicide Attempt

Surgical Implantations

Thyroid Problems

Tonsillitis

Tuberculosis

Tumors, Growths

Typhoid Fever

Ulcers

Vaginal Infections

Venereal Disease

Whooping Cough

Other______

Deaths in immediate family:

CauseAge at death

______

______

______

Social & Occupational History

Job description: ______

Work schedule: ______

Do you primarily:SitStandPerform repetitive tasks

Recreational activities: ______

Lifestyle

Alcohol Frequency per week or month: ______

TobaccoPacks/ # of cigarettes a week: ______

Drug useType: ______Frequency per week or month: ______

ExerciseFrequency per week: ______Type of exercise: ______

______

Payment Authorization

Who is responsible for your bill? Self Health Insurance Worker’s CompAuto Insurance

Personal Health Insurance Carrier:______Insurance Card ID # ______

Policy Holder’s Name ______Holder’s Date of Birth ______Group # ______

Primary Care Physician ______Phone # ______

Worker’s Compensation Injury/ Auto/ Personal Injury:

Have you filed an injury report with your employer? Yes NoDate:______Time: ______AM/PM

I understand that my health insurance company has agreed to pay for services in accordance with their policies and directives whereby I am bound by their decisions pursuant to these policies, directives, and procedures.

I further understand that not all services may be covered by my insurance company in accordance with their aforementioned policies, directives, and procedures. Should my insurance company make such a determination that they are unwilling to pay for the services rendered, and I have opted to receive them, I agree to personally pay for the services provided by Family Chiropractic of Clark, LLC.

I further understand that Family Chiropractic of Clark, LLC shall hold me personally responsible to pay for these services should coverage be denied, deemed not essential, or not a covered service. Should any collections fees be applied due to non-payment on my behalf, I understand that I am responsible for that fee in its entirety.

Patient Signature: ______Witness:______

HIPAA Privacy Practices

I acknowledge that I have received and/or have been given the opportunity to review the Notice of HIPAA Privacy Practices for protected health information.

Print Patient’s Name ______

Patient’s Signature ______Date______

Consent to Treat a Minor: (Parent/Guardian’s Name) ______

Parent/Guardian’s Signature ______Date______