Patient: Richard Allgood

Patient: Richard Allgood Date: May 16, 2006

History Report

General Patient's information Patient's full name : Richard Allgood File number : 0002563 Medical security number : Patient's date of birth : October 5, 1962 Patient's age : 44 years old

Richard Allgood came to our office on May 16, 2006 for evaluation and treatment of his complaints. I have prepared this brief report outlining the need for past and future treatments. Following is the patient s brief description of his complaints as well as the description of related injuries. I am also submitting the results of my examination findings that mandate the necessity for care.

Subjective Complaints

Richard Allgood stated that he is primarily suffering from throbbing pain located at the central posterior cranial region. He reported that the onset on this symptomatology was two to four year(s) ago. The problem appears to be present 50% to 75% of time awake or two to four times per week. He rated the pain as being 9/10 using a visual analog scale with 10 being extreme pain. The patient also reported that the symptoms are most intense upon awake. He claims that he does not know how that symptomatology started. Richard Allgood also mentioned that the symptomatology was diminished while lying down and with medication. Patient states that this condition has been affecting his ability to participate in sports, drive, exercise, rise from a seated position and work. Also, Richard Allgood stated that the symptoms worsened when exposed to bright light, when exposed to loud noises and when turning the head. Richard Allgood is affected by accompanying headache and migraines. Additionally, Richard Allgood declared that he had been to a medical doctor for this condition and that the condition showed minor improvement. The patient stated that his secondary condition is aching pain and numbness located at the right posterior shoulder apex region radiating to the back of the right hand, the right posterior brachial area and the right posterior cubital region. The problem appears to be present 25% to 50% of time awake. He rated the pain as being 4/10 using a visual analog scale with 10 being extreme pain. He claims that the symptomatology appeared suddenly following a work injury.

Work injury details:

Richard Allgood claims to have been injured at work two to four years ago. The injury involved lifting. The employer was notified regarding this injury. Richard Allgood also mentioned that the symptomatology was diminished while exercising and with massage.

The patient states that this condition has been affecting his ability to drive and sleep. Also, Richard Allgood stated that the symptoms worsened when pulling, when lifting, while reclining and when driving. Richard Allgood is affected by accompanying arm pain. Additionally, Richard Allgood declared that he had been to another chiropractor for this condition and that the condition showed significant improvement. Richard Allgood also reported that his tertiary condition is burning pain located at the lateral aspect of the right gluteal region. He reported that the onset on this symptomatology was on May 2, 2006 or two to four week(s) ago. The problem appears to be present 75% to 100% of time awake. He rated the pain as being 3/10 using a visual analog scale with 10 being extreme pain. The patient also reported that the symptoms are most intense in the afternoon. The symptomatology appeared following a trauma injury.

Trauma injury details:

He claims to have fallen while he was participating in sports. Richard Allgood also mentioned that the symptomatology was diminished when heat was applied, while lying down and with medication. The patient states that this condition has been affecting his ability to sit. Also, Richard Allgood stated that the symptoms worsened while bending, when pulling, when lifting and when sitting.

Remarks: Richard Allgood was evaluated in our office using a Visual Analog Scale. This subjective rating model has been found to be highly reproducible in qualifying a patient's subjective pain (Huskisson EC: 'Measurement of Pain', Lancet 2, pages 1127-1131, and Scott J, Huskisson EC: 'Accuracy of Subjective Measurements', Ann Rheum Dis, 38.

Dr Frank Poe, Chiropractor Permit number: 93117-/9 1017 Oak, Madisson, WI 85962 Phone number: 809-659-5689 Fax number: 809-659-5656