Dr.

Bruggeman
Initial Visit

Last Name First Name Middle Name MRN
This form is used to gather information so that my doctor can maximize the time used to examine
me and answer my questions about my condition and treatment options. certify that the following
information is correct to the best of my !nowledge. will not hold my doctor or any members of
his"her staff responsible for any errors or omissions that may ma!e in the completion of this form.
#atient $ignature %&ate'
(aref u lly
read the
following
definitions
Definitions
#ain Le)els The le)el of pain you ha)e had o n a ) e ra g e since your problem began
Nec! #ain *Nec!+ includes middle of nec!, upper shoulders, between shoulder blades
-rm #ain *-rm+ includes shoulder, arm, or hand
.ac! #ain *.ac!+ includes pain a bo ) e the belt line across the lower bac!
Leg #ain *Leg+ includes areas b e low the belt line including the buttoc!, legs, or feet
-ge /and &ominance 0ender 1hat is the main complaint you wish to discuss2
Right Male
Left Female
1hat was the approximate date your problem started2
1hich best describes the onset of the problem 0radual 3nset $udden 3nset
f sudden onset, what were you doing when it started2
i.e. fell off ladder, golfing, lifting groceries
&id your problem begin with a car accident2 No 4es
f yes5 1ere you the dri)er2
No 4es
1ere you wearing a seatbelt2
No 4es
&id you pass out2
No 4es
When did you first
seek medical
attention?
Less than 6
month ago
678 months
ago
879 months
ago
9 months to
6 year ago
6 7: years
ago
More than :
years ago
For a total of 6;;<, what < is bac! pain and what < is leg2 < Low .ac! #ain < Leg #ain
%i.e. 8;< low bac! pain with =;< leg pain'
> ?6;;<
For a total of 6;;<, what < is nec! pain and what < is arm2 < Nec! #ain < -rm #ain
%i.e. :;< nec! pain with @;< arm pain'
> ?6;;<
Your level of pain
from 0 to 10
; 6 : 8 A B 9 = @ C 6;
Less #ain 1orse #ain
Nec! #ain
Right -rm #ain
Left -rm #ain
Low .ac! #ain
Right Leg #ain
Left Leg #ain
Using the symbols,
mark the location and
type of pain on the
diagrams
f you ha)e pain into the
lower leg, feet, or hands,
ma!e sure you note it
RI!" #$%" #$%" RI!"
Type of $ensation5
$tabbing".urning5
D
-ching5 E
#ins and Needles5 7
Numbness5 3
&o you have' No 4es Fxplain where
Numbness in the arms"hands or legs"feet2
1ea!ness in the arms"hands or legs"feet2

Rest
Laying
flat
$itting
1al!ing on
flat surfaces
1al!ing
up stairs
1al!ing
down stairs
.ending
" twisting
3ther
%&escribe'
#ain worse with
#ain better with
&o you have' No 4es
Loss of bowel control2 %difficulty controlling"initiating bowel mo)ements or incontinence'
Loss of bladder control2 %difficulty controlling"initiating urination or incontinence'
.alance problems from leg wea!ness2
.alance problems not from wea!ness but from lac! of coordination2
#roblems handling small obGects such as coins or problems buttoning your shirts2
"reatment history No 4es &etails %f 4es'
Made my pain5
.etter No (hange 1orse
-nti nflammatory pain
medicine %ie Motrin, -le)e'
Medication5
Narcotics
%ie Hicodin, #ercocet'
Medication5
Fpidurals or $electi)e
Ner)e Root inGections
/ow many5
&ate of last inGection5
#hysical Therapy /ow long5
#hysiatrist %#ain $pecialist' Name5
-cupuncture Name5
(hiropractor Name5
(edical history
)ie' !igh blood pressure, asthma, high cholesterol, etc*
ha)e no medical problems
&o you ha)e history of cancer2
No 4es &etails %f 4es'
Type5 #rior treatment5
+urgical history
)i,e,'"onsillectomy, hip replacement, heart surgery, etc*
ha)e not had surgery in the past
&ate of $urgery $urgery %$pecify Right or Left side if rele)ant'
#ist -## medications, vitamins, and supplements you
are currently taking, )(ay attach list of medications*
currently ta!e no medications
-llergic reactions including medicines, iodine,
intravenous dye, late., shellfish, etc
ha)e no allergies
Medication"$ubstance -llergic Reaction
/ccupational0+ocial history
am currently retired
1hat is your occupation2

No 4es &etails %f 4es'

-re you out of wor! due to your spinal condition2
/ow long ha)e you been
out of wor!2
&o you ha)e a wor!manIs compensation claim2 &ate of wor! inGury5
&o you smo!e cigarettes2
/ow many pac!s per day2
For how many years2
&o you smo!e a pipe or cigars2 /ow often2
&o you dip snuff or chew tobacco2 /ow often2
&o drin! alcohol2 /ow many drin!s per wee!2
&o you use any street drugs2 1hich drugs and how often2
1ho do you li)e with2
%amily history of disease
ha)e no family history of disease
Relationship &isease Relationship &isease
Revie1 of systems

General
Eye,Ear Nose,Throat
Musculoskeletal

Psychiatric
Fe)er or (hills &ifficulty swallowing Joint pains -nxiety
&izziness /earing loss Muscle aches &epression
Fainting spells /oarseness -n!ylosing spondylitis #sychiatric hospitalization
Fatigue Nose bleeds 1ea! bones #anic attac!s
Frequent headaches Ringing in ears Rheumatoid arthritis $uicidal thoughts
nsomnia $inus problems 3steoarthritis #sychiatric drugs
$weats .lurry )ision .one cancer Memory loss
1eight changes #oor )ision .one infections 3ther5
3ther5 3ther5 3ther5 MEN only
Cardiovascular Gastrointestinal Genitourinary .reast lumps
-n!le swelling #oor appetite .ladder control Fnlarged prostate
(hest pains .owel changes .lood in urine Frectile dysfunction
Fnlarged heart (onstipation Frequent urination #enis discharge
/eart attac! &iarrhea Kidney stones #rostate cancer
/eart murmur Fxcessi)e thirst #ainful urination 3ther5
/eart palpitations /eartburn Lrgent urination
WOMEN only
/igh blood pressure Nausea 1ea! stream -bnormal pap smear
$hortness of breath Rectal bleeding 3ther5 .reast lumps
rregular heartbeat $tomach pain
Neurological Haginal discharge
#rolonged bleeding Llcers Loss of motor control $e)ere menstrual pain
/istory of blood clots Homiting 1ea!ness /ot flashes
3ther5 3ther5
#aralysis -ll other R3$ Negati)e
Endocrine kin
#oor balance
.lood sugar problem .ruise easily $eizures
Lse of steroids Foot ulcers $peech difficulties
3)er acti)e thyroid Rashes Tremors
Lnder acti)e thyroid $ores that wonIt heal Muscle wasting
3ther5 3ther5 3ther5
3ffice Lse 3nly /eight 1eight .#
"
#ulse