INITIAL PATIENT EVALUATION Broeg Chiropractic & Nutrition Center

Name: ______Signature:______Date:______File#: ______

PRESENT HISTORY: Check Correct Item or Fill in Blank(s) 1. The problem(s) that have prompted me to seek care today include: ______

2. When did the present problem(s) start? (month/day/year). If more than 1 problem, list date for each. ______

3. How did the problem start? (check appropriate box).  Suddenly  No apparent cause  Injured at work  Injured in Auto Accident  Gradually  Worsening/Recurrence  Other (specify): ______

4. Have you had any trouble with this problem before?  No  Yes When was the FIRST time? ______

5. How often you feel it: My pain/symptoms are: (check all that apply)  Daily  Present intermittently (come and goes)  Improving  ____ X per day/week/month/year  Always present but of variable intensity  Staying Steady Percent of waking hours you feel it _____%  Getting Worse

6. CHECK activities that make the problem worse and CIRCLE any activities you are unable to perform due to this problem,  Sit _____ minutes  Lifting/Carrying  Lay on back/side  Look- L R Up Dn  Cough/Sneeze  Stand ___ minutes  Get dressed  Twist/turn L R  Push/Pull  Exercise  Walk ___ minutes  In/out of car  Sit to stand  Grip  Up/down steps  Bending  Drive ___ mins/hrs  Shower/bath  In/out of Bed  Other ______

7. Worse at:  AM rising  Morning  Afternoon  Evening  In Bed  Unaffected by time of day

8. Does the problem affect your sleep? Emotional reactions to your current problem?  None  Wake ___ times/night  None  Discouraged/Down  Difficulty falling asleep  Difficulty staying  Frustrated/Angry  Other ______asleep

9. What reduces the pain/symptoms?  Laying down  Chiropractic Manipulation  Ice  Heat  Nothing  Medication  Exercise/Activity  Other (specify)______

10. Does your problem affect:

 Work  Social Activities  Recreational/Leisure  Sports  House or Yard Work

11. My weight is:  increasing  decreasing  steady

12. Has your current problem caused loss of bowel or bladder control?  No  Yes

13. Have you seen any other providers for your CURRENT problem?  No  Yes

List their name, date seen, diagnosis, treatment: ______14. Which of the following treatments have you had for this problem?  None

 Chiropractic Manipulation  Massage  Self Care  Epidural Steroid Injection  Physical Therapy  Exercise  Acupuncture (Cortisone shot in back) Surgery Describe: ______ Medication:______

15. Tests I have had for this problem:  None  X-rays CT Scan  EMG (Nerve Test)  MRI

Describe any positive results:______

16. Are you currently employed?  No  Yes Employer:______Occupation:______Dates off work due to this problem? ______I last worked on: ______My employer would allow me to return to work with restrictions:  No  Yes

17. GOALS: What are you hoping to gain from your treatment/care?  Other______ Pain relief ______%  Wellness/Prevention  Injury Prevention  Return to exercise  Return to work  Improve quality of life  Avoid surgery  Decrease pain with exercise  Improve ability to work  Improve sleep  Improve mobility  Decrease pain medication

PAST MEDICAL HISTORY 18. HEALTH HISTORY: (Please indicate if you have been diagnosed or treated for any of the following)  None  Anemia  Cancer Type:______ GERD  Pacemaker/Defibrillator  Anxiety  CHF (congestive heart failure)  Gout  Osteoporosis  Arthritis  Depression  Heart Attack/Heart Disease  Pneumonia  Asthma  Diabetes  High Blood Pressure  Scoliosis  Atrial Fibrillation  Drug/Alcohol Dependency  High Cholesterol/Lipids  Seizure Disorder  Bleeding Disorder  Emphysema  Kidney Disease  Sleep Apnea  Blood Clots  Enlarged Prostate  Liver Disease/Hepatitis  Stroke/TIA  COPD  Fibromyalgia  Migraines  Thyroid  Other:______ Neuropathy  Ulcer

19. CURRENT MEDICATION: If you need additional space, ask for MEDICATIONS LIST.  See Attached List  None ______

20. MEDICATION ALLERGIES: List any known allergies you have had to any medications.  No known drug allergies. ______

21. PAST SURGERIES: (Please list ALL surgeries that you have had and dates)  None ______

22. ALLERGIES: (Please indicate the type of reaction you experienced.) No Known Allergies  Latex______ Tapes/Adhesives______ Other______

23. TOBACCO USE:  Yes  Daily  Sometimes  Former  Never  ___ years ___ Pks per day  Interest in quitting  No  Yes

24. ALCOHOL USE:  No  Yes # of drinks  1-6 per day/week/mo/yr  6-12 per /day/week/mo/yr  12 or more per day/week/mo/yr

25. EXERCISE/PHYSICAL ACTIVITY:  None Describe: ______How often: ______How long?______

26. FAMILY HISTORY: (Please indicate with a check mark any diseases that run in your family)  None  Diabetes  Rheumatoid Arthritis  Stroke  Heart Disease  High Blood Pressure  Osteoporosis  Osteoarthritis  Blood Clots  Neck Problems  Back Problems

27. REVIEW OF SYSTEMS (check ALL that apply) Constitutional Cardiovascular Musculoskeletal Neuro Genitourinary  fever  chest pain  joint swelling  headaches  incontinence  chills  irregular beat  joint pain  dizziness  pregnant  weight loss  swelling in hands,  stiffness  numbness/tingling due date ______ none feet, ankles  none  visual changes # weeks ______ none  none  none Skin Stomach/GI Respiratory Hematologic Endocrine  rashes/lesions  heartburn  shortness of breath  excessive bleeding  excessive thirst  unusual bruises  trouble swallowing  cough  none  frequent urination  none  abdominal pain  none  none  none

DC Signature ______Date ______Richard A. Broeg DC Eva K. Broeg DC

BROEG CHIROPRACTIC & NUTRITION CENTER

Dear Patient:

Current laws and insurance companies require all physicians to meet guidelines for the use of electronic health records. We are required to report the Race, Primary Language, Ethnicity and specific health issues for each of our patients.

To assist us with the one-time collection of this information, please check the appropriate boxes below. Thank you for your help. If you have any questions, please ask.

 White  Black/African American  Hispanic  Asian  I choose not to specify  Other ______

Multi-Racial (check one)  No  Yes  Unknown

Ethnicity:

Ethnicity (check one)  Hispanic or Latino  Not Hispanic or Latino  I choose not to specify

Primary Language:

 English  Spanish  French  Chinese  I choose not to specify  Other______

Preferred Contact Method:

 Phone  Home  Cell  Work  Email:  Home  Work  Mail

Verification Question (choose only one question by circling the question, then give the answer to that question).  What is the name of your favorite pet?  In what city were you born?  What high school did you attend?  What is your favorite movie?  What is your mother’s maiden name?  On what street did you grow up?  What was the make of your first car?  When is your anniversary?

Verification Answer to the Chosen question: ______Answer must be at least 6 characters.

Signature Print Name Date

MU Required Information BROEG CHIROPRACTIC & NUTRITION CENTER Dr. You Are Seeing Today ______Date: ______

PATIENT INFORMATION

Patient Name ______Nickname ______Home Phone # ______Cell Phone # ______Work Phone # ______E-Mail – Home: ______Work: ______Address ______City ______ST ______Zip ______Soc Sec # ______DOB ______Age ______Gender ______Marital Status: S M Other ______Employment Status:  Employed  Self Employed  Retired  PT Student  FT Student  Other Occupation ______Employer ______Work Address ______City ______ST ______Zip ______Spouse/Partner Name or Both Parents ______Phone # ______Emergency Contact ______Relationship ______Phone # ______Yes, I would like to receive information and updates via email.  Yes  No Referred by: ______

RESPONSIBLE PARTY INFORMATION (if patient is a minor provide parent info)  Same as above

Name ______Relationship to patient ______Address ______City ______ST ______Zip ______Home Phone # ______Cell Phone # ______Work Phone # ______E-mail Address ______DOB ______Soc Sec # ______Employer & Address ______Occupation ______Employer ______

INJURY INFORMATION (if applicable)

Is this:  Work Related  Auto Accident  Other Accident Date of injury/onset ______How did injury happen? ______Area to be treated ______Were X-rays/MRI taken?  NO  Yes Where ______When ______Off work due to this injury  No  Yes If Yes, first date missed ______Insurance carrier ______Address ______City/ST/Zip ______Phone # ______Fax # ______Contact Person ______Claim # ______Injury occurred in:  Kentucky  Ohio  Other ______

INSURANCE INFORMATION

Primary Insurance Secondary Insurance Insurance Name ______Insurance Name ______Address ______Address ______

______Subscriber Name ______Subscriber Name ______Subscriber’s Date of Birth ______Subscriber’s Date of Birth ______Employer ______Employer ______Demographic