Benessere Chiropractic

295 W. Broadway

Eugene, OR 97401

Ph: (541)636-3358 F: (541)636-3270

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Chris Osterlitz,
D.C. / Wade Guthrie,
D.C. / Katherine Kinports, D.C. / Amber Rohrer,
L.M.T., C.A.
Kate Hirst
L.M.T., C.A. / Katherine Galuska,
L.M.T. / Megan Cochran,
L.M.T. / Sarah Pagen,
L.M.T.

Patient Registration

Today’s Date______

Name______Date of Birth ______

Address______Home Phone______

City______State____Zip_____ Cell Phone______

Social Security #______M__F__ Work Phone______

Employer______Occupation______email______

Marital Status: S M W D P Spouse’s Name______# of children______

How did you hear about us? ______

Emergency contact:______Phone:______

I am here today due to: _Illness _Trauma _Work Injury _Auto Accident _Other

What date did this occur?______

For Insured Patients

Primary Insurance for today’s visit: _Private Ins. _Auto _Work Comp _Medicare

Insurance Company: ______

Name of Insured:______ID No: ______

Group No:______Claim No:______Medicare No: ______

Secondary Insurance Company:______

Name of Insured:______ID No: ______

Group No:______Claim No:______Medicare No: ______

I understand that health insurance policies are an arrangement between my insurance carrier and myself. Billing is done by Benessere as a courtesy only and all services rendered to me are my personal responsibility.

I authorize the release of any medical information necessary to process my insurance claim and I authorize payment of medical benefits to this office for professional services rendered.

Patient Signature:______Date:______

Automobile Accident Insurance Data:

Auto insurance information for the vehicle you were in:

Company Name:______Phone # ______

Address:______Policy # ______

______Claim # ______

Adjuster’s Name:______

Your own auto insurance information (if different):

Company Name:______Phone # ______

Address: ______Policy # ______

______Claim # ______

Adjuster’s Name: ______

Other driver’s auto insurance information:

Company Name:______Phone # ______

Address:______Policy # ______

______Claim # ______Adjuster’s Name:______

History of Occurence

Date of Accident:______Time:______[ ] AM [ ] PM

Driver of car:______Where were you seated? ______

Owner of the car:______Year and model of car:______

What was the approximate damage done to the car you were in? $______

Visibility at the time of the accident: [ ] Poor [ ] Fair [ ] Good

Road conditions at the time of accident: [ ] Icy [ ] Rainy [ ] Wet

[ ] Clear [ ] Dark

Your car: [ ] Hit another car OR [ ] was hit in: [ ] Right [ ] Left

[ ] Rear [ ] Front [ ] Side

Type of accident: [ ]Head-on collision [ ]Broadside collision [ ]Rear-end collision

[ ] Front impact (you rear-ended car in front)

[ ] Rear impact followed by front impact (pile up)

[ ] Non-collision:______

Impact / Seat Belt / Headrest / Speed

In your own words, describe what happened to you upon impact:______Did you see the accident coming? [ ] Yes [ ] No

Were you pre-warned the accident was about to happen? [ ] Yes [ ] No

Did you brace for the impact? [ ] Yes [ ] No

Were you wearing a seat belt? [ ] Yes [ ] No

Were you wearing a shoulder harness? [ ] Yes [ ] No

Did the airbag(s) deploy? [ ] Yes [ ] No [ ] Front [ ] Side

Did your head hit: [ ] Window [ ] Steering wheel [ ] Dash [ ] Other______

Was the car you were in: [ ] Braking [ ] Stopped with foot on brake [ ] Parked

Does the car you were in have headrests? [ ] Yes [ ] No

If yes, what was the position of the headrest compared to your head before impact?

[ ] Top of headrest even with bottom of head

[ ] Top of headrest even with top of head

[ ] Top of headrest even with middle of neck

Head / Body position / Able to move body

Head/body position at time of impact:[ ]Head turned:[ ]Right [ ] Left [ ] Looking back [ ] Head straight forward [ ] Body straight, sitting [ ] Body rotated: [ ] Right [ ] Left

Immediately after impact were you: [ ] Unconscious [ ] Dazed [ ] Shaken up

Could you use all parts of your body? [ ] Yes [ ] No

If no, which parts could not and why?______

Were you able to get out of the car and walk unaided? [ ] Yes [ ] No

If no, why not?______

Symptoms from accident:

Did you get bleeding cuts and bruises? [ ] Yes [ ] No

If yes, describe bleeding cuts: ______

If yes, describe bruises: ______

As specifically as you can, please describe how you felt:

Immediately after the accident: ______

Later that [ ] day [ ] night:______

The next day(s):______

What aggravates your condition?______

What relieves your condition?______

Can you cook and clean for yourself?______

Has your sleep been affected?[ ]Yes[ ]No [ ] Due to pain, __hr/night[ ]Feel rested

If other, describe:______

Activities of daily living

Do you notice any common activities or your daily home routine that are different now from before the accident? [ ] No [ ] Yes, ______

Those activities that you are unable to do are (specific): ______

Those activities that are painful to do are (specific): ______

Those activities that are difficult to do are (specific): ______

Do you take vitamins or minerals? [ ] No [ ] Yes,______

Please list all medications: ______

Prior / similar symptoms

Did you have any physical complaints just before the accident? [ ] No [ ] Yes, ______Prior to this accident, have you EVER had symptoms similar to what you’re experiencing now? If yes, please explain (include past falls, injuries, operations, etc) [ ] No [ ] Yes,______

First doctor / hospital / clinic seen

Did you seek medical help immediately/soon after the accident? [ ] Yes [ ] No

If yes, how did you get there? [ ] Someone drove me [ ] Drove myself

[ ] Ambulance [ ] Police

Whom did you see?______Date of first visit:______

Were x-rays taken? [ ] Yes [ ] No Were you treated? [ ] Yes [ ] No

If yes, what treatment was given?______

What benefits did you receive from treatment?______

Date of last treatment: ______

Second doctor / hospital / clinic seen

Whom did you see?______Date of first visit:______

Were x-rays taken? [ ] Yes [ ] No Were you treated? [ ] Yes [ ] No

If yes, what treatment was given?______

What benefits did you receive from treatment?______

Date of last treatment: ______

Work status history

Occupation:______Have you missed time from work? [ ]Yes [ ] No

If yes, [ ] Full-time off work ______to______and ______to______

[ ] Part-time off work______to______and ______to______

[ ] Unable to work since the accident

Have you ever been under chiropractic care? [ ] No [ ] Yes (names): ______

Reason for treatment: ______

Response to treatment: ______

Techniques used: ______

Have you had any x-rays, MRI, CT scans in the past several years? [ ] No [ ] Yes:

Date Test Body Region Doctor/Testing Center

______

Have you ever broken/fractured a bone?

Date: Bone/Region: Treatment: Residual symptoms:

______[ ] Yes [ ] No

______[ ] Yes [ ] No ______[ ] Yes [ ] No

Have you ever been involved in a car accident?

Date: Description: Injuries: Resolved:

______[ ] Yes [ ] No

Please list all surgeries or major illnesses.

Date: Description: Resolved:

______[ ] Yes [ ] No

Other injuries (falls, concussions, trauma):

Date: Description: Resolved:

______[ ] Yes [ ] No

Heavy Moderate Light None Do you wear?

Alcohol [ ] [ ] [ ] [ ] [ ] Orthotics

Tobacco [ ] [ ] [ ] [ ] [ ] Heel lifts

Coffee [ ] [ ] [ ] [ ] [ ] Insoles

Exercise [ ] [ ] [ ] [ ] [ ] Arch supports

Sleep [ ] [ ] [ ] [ ]

Appetite [ ] [ ] [ ] [ ]

Pain Drawing

Name:______Date:______

Mark as follows:

A = Ache B = Burning N = Numbness P = Pins & Needles

S = Stabbing O = Other, describe ______

Please indicate on the diagram how the accident happened.

Payment Policy

We require payment at the time of service. If you have private health insurance we ask that you pay your co-pay or co-insurance at the time of service. If you have a yearly deductible, you must meet that as your policy specifies. We will bill, or you may bill, your insurance company. If payment for any part of your treatment is denied by an insurance carrier you will assume full responsibility for payment and will pay independent of any appeal process with the insurance carrier.

In the case of either personal injury, auto accident, or workers’ compensation claims, we will bill the entire amount of each visit to your insurance company. The cost of supplies, supports and/or supplements not paid for by your insurance company are your responsibility.

If you have any questions concerning our payment policy, please feel free to ask the receptionist.

Cancellation Policy

We require 24 hours notice for all cancellations. If you cancel with less than 24 hours notice, you will be charge 50% of the total charges for the scheduled visit. If you fail to keep your appointment and do not call to cancel, you will be charge IN FULL for the total visit. We make reminder calls as a courtesy, however, it is your responsibility to remember and come to your appointments.

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I have read and understood the above payment and cancellation policies and agree to follow them while utilizing the services at Benessere Chiropractic.

Signed______Date______