Dr. Evan Riggleman DC, ATC, D.Psc, BCIM

Dr. Evan Riggleman DC, ATC, D.PSc, BCIM

Dr. Erica Riggleman DC, MS, D.PSc, BCIM

611 W. Jubal Early Dr., Suite A2, Winchester, VA 22601 540-678-1212

* Wear or bring shorts and t-shirt

* Any recent blood work (within the last year)

* Have packet completely filled out

Vision: A Primary Healthcare Center dedicated to optimizing the health and well- being of our patients.

Mission: Add Value to your life!

Goals:

1) To do appropriate testing on each patient to find the root cause of their condition.

2) To prevent neurological degeneration. (brain and nerve damage)

3) To return you to the most optimal state of health possible.

4) To enhance, extend, and have maximum positive impact on your life.

Brain & Body Health Center CONFIDENTIAL PATIENT INFORMATION (Please Print)

Date: ______E-mail Address: ______Full Name: ______Name of Wife, Husband, or Guardian: ______Address: ______City: ______State: ______Zip Code: ______Telephone Number: ( ) ______Cell Phone Number: ( ) ______Social Security No.: _____ -- ______-- ______Male: _____ Female: ______Birth Date: ______No. of children: ______Currently Pregnant? ______Marital Status: S___ M___ D___ W___ Student: No ____ Part time ____ Full time ____ Occupation: ______Employer’s Name / Phone #: ______Spouse’s Occupation/Employer: ______Name and Phone # of Emergency Contact: ______How did you hear about our office? ______

INSURANCE INFORMATION

Primary Insurance Co. ______Subscriber’s Name ______Relationship to Patient ______Subscriber’s Birth Date ______Subscriber’s SS# ______Subscriber’s Employer ______Is patient covered by addition insurance? ______Yes ______No

Secondary Insurance Co. ______Subscriber’s Name ______Relationship to Patient ______Subscriber’s Birth Date ______Subscriber’s SS# ______Subscriber’s Employer ______

List Chiropractors you have seen before: 1) Name: ______When Visited ______2) Name: ______When Visited ______

List Medical Doctors consulted within the past year: 1) Name: ______Reason for visit? ______2) Name: ______Reason for visit? ______

Please list all your reasons for visiting our office: 1) ______4) ______2) ______5) ______3) ______6) ______List ALL medications you take. (Prescription & over-the-counter- use additional pages if needed)

Drug Name: Dosage: How long have you taken & for what conditions? ______

List ALL vitamins you take. (Use additional pages if needed) Supplement: Dosage: How long have you taken & for what condition? ______

List ALL previous hospitalizations, surgeries, accidents, fractures & illnesses (use extra pages) (Example: All past Auto, Sports, Work, Home related.)

1) Type ______When ______Hospitalized? Yes_____ No_____ 2) Type ______When ______Hospitalized? Yes_____ No_____ 3) Type ______When ______Hospitalized? Yes_____ No_____ 4) Type ______When ______Hospitalized? Yes_____ No_____

Check ALL “body signals” (symptoms/pain) you may have had or do have now:

___ADD/ADHD ___Depression ___Hepatitis ___Miscarriage ___Alcoholism ___Diabetes ___High Blood Pressure ___Multiple Sclerosis ___Allergy ___Diarrhea ___High Cholesterol ___Neck Pain ___Alzheimer’s ___Eczema ___High Blood Sugar ___Parkinson’s ___Anemia ___Emphysema ___HIV/AIDS ___Pneumonia ___Appendicitis ___Epilepsy/seizures ___Irregular Periods/Cramps ___Raynaud’s ___Asthma ___Fibromyalgia ___Irritable Bowel ___Rheumatoid Arth. ___Arthritis ___Gall Bladder ___Kidney infections/stones ___Ringing in Ears ___Back Pain ___Goiter ___Low Blood Pressure ___Sinus Infections ___Cancer ___Gout ___Low Blood Sugar ___Stroke ___Celiac Disease ___Headaches ___Lyme Disease ___Thyroid Problems ___Chronic Fatigue ___Heart Attack ___Lupus ___Ulcers ___Constipation ___Heart Disease ___Migraine ___Vertigo/Dizziness

Has any of your close family been diagnosed with any of the following?

___Alzheimer’s ___Cancer ___Diabetes ___Heart Dz ___Parkinson ___MS ___Stroke ___Parkinson’s

If Yes, Who? ______List any other health conditions that you or your family have had that are not listed on the previous page: ______

Do you consume any of the following? (Leave blank what doesn’t apply)

Tobacco products (packs/day) ______How many years? ______Alcohol drinks/day ______How many years? ______Coffee/Tea cups/day ______Regular or Decaf? ______Soft drinks #/day ______Regular or Diet? ______

Do you use artificial sweeteners? ___Yes ___No If yes, please list ______

Level of exercise? _____None _____Moderate (days/week) _____Strenuous (days/week)

Have you experienced any unexplained or rapid weight changes in the last six months? ____Yes ____No ____Lbs.

Please mark off the areas of your complaint on the diagram below. Use the following symbols: P = pain, N = numbness, T = tingling, B = burning, C = cramping

COMPLAINT HISTORY

Complaint 1: ______When did your complaint first begin? ______Ever experience this before? ______What makes your problem better? ______What makes your problem worse? ______Describe the type of pain/symptom you experience? ______Does your problem travel into any other part of your body? Where? ______Where exactly is the complaint area? ______Have you lost control of any body part (arms, legs, bladder, bowel, etc)? ______Rate the severity of your problem on a scale of 1-10, (1 = least severe, 10 = bedridden)? ______

Complaint 2: ______When did your complaint first begin? ______Ever experience this before? ______What makes your problem better? ______What makes your problem worse? ______Describe the type of pain/symptom you experience? ______Does your problem travel into any other part of your body? Where? ______Where exactly is the complaint area? ______Have you lost control of any body part (arms, legs, bladder, bowel, etc)? ______Rate the severity of your problem on a scale of 1-10, (1 = least severe, 10 = bedridden)? ______

Complaint 3: ______When did your complaint first begin? ______Ever experience this before? ______What makes your problem better? ______What makes your problem worse? ______Describe the type of pain/symptom you experience? ______Does your problem travel into any other part of your body? Where? ______Where exactly is the complaint area? ______Have you lost control of any body part (arms, legs, bladder, bowel, etc)? ______Rate the severity of your problem on a scale of 1-10, (1 = least severe, 10 = bedridden)? ______ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with ______and assign directly to Dr. Riggleman all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charge whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above name doctor may use my health care information and may disclose such information to the above named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. In addition, I give Dr. Riggleman consent to treat utilizing the recommended care.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Brain & Body Health Center may prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Brain & Body Health Center, will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me, and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered, to me, will be due immediately and payable at the regular fee schedule. I understand that I am responsible for all attorney fees or collection fees related to the collection of my account. I agree to pay interest at the rate of 1.5% per month (18% per annum) on any unpaid balance.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT AND AUTHORIZATION FOR TREATMENT, FINANCIAL RESPONSIBILITY, RELEASE OF MEDICAL INFORMATION AND INSURNACE PAYMENTS. FURTHER, I ACKNOWLEDGE THAT I HAVE BEEN GIVEN A COPY OF THIS OFFICE’S PATIENT CONFIDENTIALITY POLICY TO READ FOR MY INFORMATION AND TO KEEP FOR MY RECORDS.

Patient Signature ______Date ______NOTICE OF PRIVACY PRACTICES I have been asked/received a copy of the HIPAA Privacy Regulations and understand that my private healthcare information is protected.

I authorize Brain & Body Health Center, LLC, to release information regarding the above named patient to: (Name, telephone number, relationship to patient, example: mother, father, spouse, etc., please note that ONLY THE NAME LISTED will be able to obtain medical information about you.

*May we leave a message for you on your answering device? Yes______No______

Name______Phone Number______Relationship______

Patient Signature ______Date ______METABOLIC ASSESSMENT FORM

PART 1 Please list your 5 major health concerns in order of importance: 1. ______2. ______3. ______4. ______5. ______

PART 2 Please circle the appropriate number on all questions below. (0 as the least/never to 3 as the most/always)

Category I peppers, alcohol, and caffeine 0 1 2 3 Feeling that bowels do not empty completely 0 1 2 3 Category VI Lower abdominal pain relieved by passing stool or gas 0 1 2 3 Roughage and fiber cause constipation 0 1 2 3 Alternating constipation and diarrhea 0 1 2 3 Indigestion and fullness last 2-4 hours after eating 0 1 2 3 Diarrhea 0 1 2 3 Pain, tenderness, soreness on left side under rib cage 0 1 2 3 Constipation 0 1 2 3 Excessive passage of gas 0 1 2 3 Hard, dry, or small stool 0 1 2 3 Nausea and/or vomiting 0 1 2 3 Coated tongue or “fuzzy” debris on tongue 0 1 2 3 Stool undigested, foul smelling, mucous like, Pass large amount of foul-smelling gas 0 1 2 3 greasy, or poorly formed 0 1 2 3 More than 3 bowel movements daily 0 1 2 3 Frequent urination 0 1 2 3 Use laxatives frequently 0 1 2 3 Increased thirst and appetite 0 1 2 3

Category II Category VII Increasing frequency of food reactions 0 1 2 3 Greasy or high-fat foods cause distress 0 1 2 3 Unpredictable food reactions 0 1 2 3 Lower bowel gas and/or bloating several hours Aches, pains, and swelling throughout the body 0 1 2 3 after eating 0 1 2 3 Unpredictable abdominal swelling 0 1 2 3 Bitter metallic taste in mouth, especially in the morning 0 1 2 3 Frequent bloating and distention after eating 0 1 2 3 Burpy, fishy taste after consuming fish oils 0 1 2 3 Abdominal intolerance to sugars and starches 0 1 2 3 Difficulty losing weight 0 1 2 3 Unexplained itchy skin 0 1 2 3 Category III Yellowish cast to eyes 0 1 2 3 Intolerance to smells 0 1 2 3 Stool color alternates from clay colored to normal brown 0 1 2 3 Intolerance to jewelry 0 1 2 3 Reddened skin, especially palms 0 1 2 3 Intolerance to shampoo, lotion, detergents, etc. 0 1 2 3 Dry or flaky skin and/or hair 0 1 2 3 Multiple smell and chemical sensitivities 0 1 2 3 History of gallbladder attacks or stones 0 1 2 3 Constant skin outbreaks 0 1 2 3 Have you had your gallbladder removed? Yes No

Category IV Category VIII Excessive belching, burping, or bloating 0 1 2 3 Acne and unhealthy skin 0 1 2 3 Gas immediately following a meal 0 1 2 3 Excessive hair loss 0 1 2 3 Offensive breath 0 1 2 3 Overall sense of bloating 0 1 2 3 Difficult bowel movements 0 1 2 3 Bodily swelling for no reason 0 1 2 3 Sense of fullness during and after meals 0 1 2 3 Hormone imbalances 0 1 2 3 Difficulty digesting fruits and vegetables; Weight gain 0 1 2 3 undigested foot found in stools 0 1 2 3 Poor bowel function 0 1 2 3 Excessively foul-smelling sweat 0 1 2 3 Category V Stomach pain, burning, or aching 1-4 hours after eating 0 1 2 3 Category IX Use of antacids 0 1 2 3 Crave sweets during the day 0 1 2 3 Feel hungry an hour or two after eating 0 1 2 3 Irritable if meals are missed 0 1 2 3 Heartburn when lying down or bending forward 0 1 2 3 Depend on coffee to keep going/get started 0 1 2 3 Temporary relief by using antacids, food, milk, or Get light-headed if meals are missed 0 1 2 3 carbonated beverages 0 1 2 3 Eating relieves fatigue 0 1 2 3 Digestive problems subside with rest and relaxation 0 1 2 3 Feel shaky, jittery, or have tremors 0 1 2 3 Heartburn due to spicy foods, chocolate, citrus, Agitated, easily upset, nervous 0 1 2 3 Poor memory/forgetful 0 1 2 3 Blurred vision 0 1 2 3 Category X Category XVI Fatigue after meals 0 1 2 3 Increased sex drive 0 1 2 3 Crave sweets during the day 0 1 2 3 Tolerance to sugars reduced 0 1 2 3 Eating sweets does not relieve cravings for sugar 0 1 2 3 “Splitting” – type headaches 0 1 2 3 Must have sweets after meals 0 1 2 3 Waist girth is equal or larger than hip girth 0 1 2 3 Category XVII (Males Only) Frequent urination 0 1 2 3 Urination difficulty or dribbling 0 1 2 3 Increased thirst and appetite 0 1 2 3 Frequent urination 0 1 2 3 Difficulty losing weight 0 1 2 3 Pain inside of legs or heels 0 1 2 3 Feeling of incomplete bowel emptying 0 1 2 3 Category XI Leg twitching at night 0 1 2 3 Cannot stay asleep 0 1 2 3 Crave salt 0 1 2 3 Category XVIII (Males Only) Slow started in the morning 0 1 2 3 Decreased libido 0 1 2 3 Afternoon fatigue 0 1 2 3 Decreased number of spontaneous morning erections 0 1 2 3 Dizziness when standing up quickly 0 1 2 3 Decreased fullness of erections 0 1 2 3 Afternoon headaches 0 1 2 3 Difficulty maintaining morning erections 0 1 2 3 Headaches with exertion or stress 0 1 2 3 Spells of mental fatigue 0 1 2 3 Weak nails 0 1 2 3 Inability to concentrate 0 1 2 3 Episodes of depression 0 1 2 3 Category XII Muscle soreness 0 1 2 3 Cannot fall asleep 0 1 2 3 Decreased physical stamina 0 1 2 3 Perspire easily 0 1 2 3 Unexplained weight gain 0 1 2 3 Under a high amount of stress 0 1 2 3 Increase in fat distribution around chest and hips 0 1 2 3 Weight gain when under stress 0 1 2 3 Sweating attacks 0 1 2 3 Wake up tired even after 6 or more hours of sleep 0 1 2 3 More emotional than in the past 0 1 2 3 Excessive perspiration or perspiration with little or no activity 0 1 2 3 Category XIX (Menstruating Females Only) Perimenopausal Yes No Category XIII Alternating menstrual cycle lengths Yes No Tired/sluggish 0 1 2 3 Extended menstrual cycle (greater than 32 days) Yes No Feel cold – hands, feet, all over 0 1 2 3 Shortened menstrual cycle (less than 24 days) Yes No Require excessive amounts of sleep to function properly 0 1 2 3 Pain and cramping during periods 0 1 2 3 Increase in weight even with low-calorie diet 0 1 2 3 Scanty blood flow 0 1 2 3 Gain weight easily 0 1 2 3 Heavy blood flow 0 1 2 3 Difficult, infrequent bowel movements 0 1 2 3 Breast pain and swelling during menses 0 1 2 3 Depression/lack of motivation 0 1 2 3 Pelvic pain during menses 0 1 2 3 Morning headaches that wear off as the day progresses 0 1 2 3 Irritable and depressed during menses 0 1 2 3 Outer third of eyebrow thins 0 1 2 3 Acne 0 1 2 3 Thinning of hair on scalp, ace, or genitals, or Facial hair growth 0 1 2 3 excessive hair loss 0 1 2 3 Hair loss/thinning 0 1 2 3 Dryness of skin and/or scalp 0 1 2 3 Mental sluggishness 0 1 2 3 Category XX (Menopausal Females Only) How many years have you been menopausal? ______years Category XIV Since menopause, do you ever have uterine bleeding? Yes No Heart palpitations 0 1 2 3 Hot flashes 0 1 2 3 Inward trembling 0 1 2 3 Mental fogginess 0 1 2 3 Increased pulse even at rest 0 1 2 3 Disinterest in sex 0 1 2 3 Nervous and emotional 0 1 2 3 Mood swings 0 1 2 3 Insomnia 0 1 2 3 Depression 0 1 2 3 Night sweats 0 1 2 3 Painful intercourse 0 1 2 3 Difficulty gaining weight 0 1 2 3 Shrinking breasts 0 1 2 3 Facial hair growth 0 1 2 3 Category XV Acne 0 1 2 3 Diminished sex drive 0 1 2 3 Increased vaginal pain, dryness, or itching 0 1 2 3 Menstrual disorders or lack of menstruation 0 1 2 3 Increased ability to eat sugars without symptoms 0 1 2 3