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)
2)
3)
4)
To do appropriate testing on each patient to find the root cause of their condition.
To prevent neurological degeneration. (brain and nerve damage)
To return you to the most optimal state of health possible.
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) ________________________________
2) ________________________________
3) ________________________________
4) _________________________________
5) _________________________________
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)
2)
3)
4)
Type __________________
Type __________________
Type __________________
Type __________________
When ___________
When ___________
When ___________
When ___________
Hospitalized?
Hospitalized?
Hospitalized?
Hospitalized?
Yes_____
Yes_____
Yes_____
Yes_____
No_____
No_____
No_____
No_____
Check ALL “body signals” (symptoms/pain) you may have had or do have now:
___ADD/ADHD
___Alcoholism
___Allergy
___Alzheimer’s
___Anemia
___Appendicitis
___Asthma
___Arthritis
___Back Pain
___Cancer
___Celiac Disease
___Chronic Fatigue
___Constipation
___Depression
___Diabetes
___Diarrhea
___Eczema
___Emphysema
___Epilepsy/seizures
___Fibromyalgia
___Gall Bladder
___Goiter
___Gout
___Headaches
___Heart Attack
___Heart Disease
___Hepatitis
___High Blood Pressure
___High Cholesterol
___High Blood Sugar
___HIV/AIDS
___Irregular Periods/Cramps
___Irritable Bowel
___Kidney infections/stones
___Low Blood Pressure
___Low Blood Sugar
___Lyme Disease
___Lupus
___Migraine
___Miscarriage
___Multiple Sclerosis
___Neck Pain
___Parkinson’s
___Pneumonia
___Raynaud’s
___Rheumatoid Arth.
___Ringing in Ears
___Sinus Infections
___Stroke
___Thyroid Problems
___Ulcers
___Vertigo/Dizziness
Has any of your close family been diagnosed with any of the following?
___Alzheimer’s
___Parkinson
___Cancer
___MS
___Diabetes
___Stroke
___Heart Dz
___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)
Alcohol drinks/day
Coffee/Tea cups/day
Soft drinks #/day
_______
_______
_______
_______
Do you use artificial sweeteners?
___Yes ___No
Level of exercise?
_____Moderate (days/week) _____Strenuous (days/week)
_____None
How many years?
How many years?
Regular or Decaf?
Regular or Diet?
_______
_______
_______
_______
If yes, please list _______________
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
Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard, dry, or small stool
Coated tongue or “fuzzy” debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
Category II
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains, and swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distention after eating
Abdominal intolerance to sugars and starches
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
Category III
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc.
Multiple smell and chemical sensitivities
Constant skin outbreaks
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category IV
Excessive belching, burping, or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables;
undigested foot found in stools
Category V
Stomach pain, burning, or aching 1-4 hours after eating
Use of antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids, food, milk, or
carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus,
peppers, alcohol, and caffeine
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0 1 2 3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0 1 2 3
0 1 2 3
0 1 2 3
Category VI
Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling, mucous like,
greasy, or poorly formed
Frequent urination
Increased thirst and appetite
Category VII
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours
after eating
Bitter metallic taste in mouth, especially in the morning
Burpy, fishy taste after consuming fish oils
Difficulty losing weight
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1
0 1
0 1
0 1
0 1
0 1
0 1
0 1
0 1
0 1
Yes
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
No
Category VIII
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Category IX
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory/forgetful
Blurred vision
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Category X
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Category XI
Cannot stay asleep
Crave salt
Slow started in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category XII
Cannot fall asleep
Perspire easily
Under a high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little
or no activity
Category XIII
Tired/sluggish
Feel cold – hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, ace, or genitals, or
excessive hair loss
Dryness of skin and/or scalp
Mental sluggishness
0 1 2 3
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
0 1 2 3
0 1 2 3
0 1 2 3
Category XIV
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight
0
0
0
0
0
0
0
Category XV
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
0 1 2 3
0 1 2 3
0 1 2 3
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
Category XVI
Increased sex drive
Tolerance to sugars reduced
“Splitting” – type headaches
0 1 2 3
0 1 2 3
0 1 2 3
Category XVII (Males Only)
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category XVIII (Males Only)
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
Category XIX (Menstruating Females Only)
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning
Yes
Yes
Yes
Yes
0 1
0 1
0 1
0 1
0 1
0 1
0 1
0 1
0 1
No
No
No
No
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
Category XX (Menopausal Females Only)
How many years have you been menopausal?
_______ years
Since menopause, do you ever have uterine bleeding?
Yes No
Hot flashes
0 1 2 3
Mental fogginess
0 1 2 3
Disinterest in sex
0 1 2 3
Mood swings
0 1 2 3
Depression
0 1 2 3
Painful intercourse
0 1 2 3
Shrinking breasts
0 1 2 3
Facial hair growth
0 1 2 3
Acne
0 1 2 3
Increased vaginal pain, dryness, or itching
0 1 2 3