Welcome To Our Office CASE HISTORY: Patient s Name: Street/City/State/ZIP Email Address: Home Phone: Work Phone: Birthdate: Age: Sex: Martial Status: M S W D Social Security #: Driver s License#: Spouse s Name: Number of Children/Ages: Your Employer s Name/Address/Phone: Your Spouse s Employer/Address/Phone: Person Responsible for This Account: How did you hear about or why did you choose our office? (check all that apply) Another Patients (name: ) Yellow Pages La Crosses Tribune Ad Another Ad (name it: ) Office Sponsored Event (where? ) My Insurance covers here. Location of office. Preferred Gonstead Practioner Another Health Care Provider/Professional (name: ) Other: What is your main complaint? How long have you had this condition? Have you had similar conditions in the past? Y N What things aggravate your condition? Is your condition getting worse? Y N Does it interfere with your activities of daily living? Y N Are you taking medications? If yes, list. Any past surgeries? Y N Other doctors seen for this condition: MD DC DO PT INSURANCE INFORMATION: Name/Address/Phone of Insurance Carrier: Are you the policyholder? Y N If no, who is? Policyholder s birthdate: Group#: Do you have a Secondary Insurance Carrier? Y N If yes, Name/Address/Group#:/Insured Name/SS#/BDate: Payment is due within 30 days of treatment or the sale of a product. A 1% per month (12% per year) late payment fee will be assessed on any unpaid balance remaining after 30 days. **As a courtesy to our patients with insurance coverage, we will call your insurance carrier to check on your benefits for care at our office. However, insurance companies DO NOT GUARANTEE BENEFITS OVER THE PHONE, therefore the information we receive is not guarantee of payment. If you have concerns regarding your insurance benefits, please call your insurance company or refer to your benefit booklet. Your policy is an agreement between you and your insurance company, any benefits not paid by your insurance policy will be your personal responsibility. I verify that the information given about my condition/health is true to the best of my knowledge. I also understand and agree that I am personally responsible for all services rendered at the BENTZ CHIROPRACTIC CLINIC. Patients Signature: Today s Date:
IMPORTANT: Please check (X) all present symptoms. HEAD: Headache sinus (allergy) entire head back of head forehead temples migraine Head feels heavy Loss of memory Light-headedness Fainting Light bothers eyes Blurred vision Double vision Loss of vision Loss of taste Loss of balance Dizziness Loss of hearing Pain in ears Ringing in ears Buzzing in ears NECK: Pain in neck Neck pain with movement Forward Backward Turn to left Turn to right Bend to left Bend to right Pinched nerve in neck Neck feels out of place Muscle spasms in neck Grinding sounds in neck Popping sounds in neck Arthritis in neck SHOULDERS: Pain in shoulder joint (R L) Pain across shoulders Bursitis (R L) Arthritis (R L) Can t raise arm above shoulder level over head Tension in shoulders Pinched nerve in shoulders (R L) Muscle spasms in shoulders ARMS & HANDS: Pain in upper arm Pain in elbow Movement aggravated Tennis elbow Pain in forearm Pain in hands Pain in fingers Sensation of pins & needles in arms Sensation of pins & needles in fingers Numbness in arms (R L) Numbness in fingers (R L) Fingers to sleep Hands cold Swollen joints in fingers Sore joints in fingers Arthritis in fingers Loss of grip strength MID-BACK: Mid-back pain Location Pain between shoulder blades Sharp stabbing Dull ache Pain from front to back Muscle spasms Pain in kidney area CHEST: Chest pain Shortness in breath Pain around ribs Breast pain Dimpled or orange peel breast Irregular heartbeat ABDOMEN: Nervous stomach Foods can t eat Nausea Gas Constipation Diarrhea Hemorroids LOW BACK: Low back pain Upper lumbar Lower lumbar Sacroilliac Low back is worse when: working lifting stooping standing sitting sending coughing lying down (sleeping) walking Pain relieves when Slipped disk Low back feels out of place Muscle spasms Arthritis HIPS, LEGS, & FEET: Pain in buttocks (R L) Pain in hip joints (R L) Pain down leg (R L) Pain down both legs (R L) Knee pain inside outside Leg cramps Cramps in feet (R L) Pins & needles in legs (R L) Numbness of leg (R L) Numbness of feet (R L) Numbness of toes Feet feel cold Swollen ankles (R L) Swollen feet (R L) WOMEN ONLY: Menstrual pain (where) Cramping Irregularity Cycle days Birth control (type) Hysterectomy Genital cancer Discharge Color Tumors Abortions Menopause MEN ONLY: Urinary frequency Difficulty in starting Night urination Prostate pain/swelling GENERAL: Nervousness Irritable Depressed Fatigue Generally feel run-down Normal sleep Loss of sleep hrs./night Loss of weight lbs. Gain of weight lbs. Coffee cups/day Tea cup/day Cigarettes pack/day Other Diabetes Hypoglycemia REMARKS:
BENTZ CHIROPRATIC CLINIC Dr. David M. Bentz PATIENT NAME: 406 Jackson St. La Crosse, WI 54601 608-784-2255 DATE: P = PAST CONITION C = CURRENT CONDITION CONDITION Arthritis FATHER MOTHER SPOUSE BROTHERS SISTERS CHILDREN Asthma/Hay Fever-Sinus Back Bursitus Cancer Constipation Diabetes Disc Problem Emotional Emphysema Headaches Heart High Blood Pressure Insomnia Kidney Liver Nervousness Scoliosis Stomach Other
TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well being, not merely the absence of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxation. I have read and fully understand the above statements. All questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. (signature) (date) Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and Dr. Bentz has my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual period:. (signature) (date) Bentz Chiropractic Clinic 406 Jackson St. La Crosse, WI 54601 (608) 784-2255
Welcome to the Bentz Chiropractic Clinic It is the intention of the personnel of the Bentz Chiropractic Office to provide for your optimum health as thoroughly and as efficiently as your particular condition will allow. Your initial visit is spent in consultation with the doctor and staff, including a thorough examination of your spine and adjacent tissues, as well as neurologic, and muscular evaluation as indicated, and a standard x-ray study and analysis of your area or areas of concern, if indicated. On your next visit, the doctor will explain his findings, the significance of the various tests and procedures will be explained to you in detail. Recommendations specifically suited to your health care will be discussed and all of your questions answered. We ask that a parent accompany a minor child under our care. In this way misunderstandings are avoided. For our patients that have Chiropractic insurance, we will file your claims for you as long as benefits are assigned to our office. You are to pay and deductible, co-payment, or any other portion that is determined as your immediate responsibility at the time of service. After notification and/or payment are received from the insurance company, you will be billed for whatever different there might be. You may wish to consult your agent or your insurance policy for allowable benefits. Payment is due upon receipt of the billing. We offer a Fee at Time of Service option. This is a reduction of fees when the fee is paid at the time of the service and there is no paperwork to be done by this office, such as filing insurance claims or filling out reports. For our patients with no insurance coverage or patients with charges that insurance will not cover, we accept cash, check, or credit card. Examination and x-rays for all Medicare patients are non-covered benefits. Therefore, the patient must pay for these services. We do participate in the Medicare program, so your liability on covered charges is limited to Medicare s allowable charge. Please check your policy or check with your agent for allowable benefits. If you must reschedule an appointment, please give the office 24 hours notice, as there are other patients who could be scheduled in your place. A major reason for the fine reputation and rapid growth of our office is the enthusiastic recommendation of our satisfied patients. We know that you, too, will want to help others regain their lost health by telling them about Chiropractic. CHIROPRACTIC is for the entire FAMILY. Please discuss with us promptly and frankly any questions you may have regarding your care. We make every effort to avoid misunderstandings and to preserve your friendship. WE EXIST TO SERVE YOU Bentz Chiropractic Clinic 406 Jackson St. La Crosse, WI 54601 (608) 784-2255