ADAM BRUGGEMAN, M.D., PLLC

Last Name First Name

Date of Birth

Home Address Apt#

Home Phone

Email Address

Work Phone Other Phone

City State Zip Code

Race

MaritalStatus

___ Married

___ Black Non Hispanic

___ American Indian

___ Asian/Pacific Islander

___ White Non Hispanic

___ Other___ Hispanic

__Cell __Pager __Fax

(Optional)

___ Single ___ Divorced ___ Life Partner ___ Separated ___ Widowed ___ Other Language other than English

Social Security Number Gender Male Female

Preferred Pharmacy and Pharmacy Phone Number

Middle Initial Nickname/AKA

Primary Care Physician

How did you hear about us?

Referring Physician

PATIENT INFORMATION

PATIENT REGISTRATION

Last Name First Name

Date of Birth

Home Address Apt#

Home Phone Work Phone Other Phone

City State Zip Code

__Cell __Pager __Fax

Social Security Number Gender Male Female

Middle Initial Nickname/AKA

Relationship to Patient (If self, skip to Emergency Contact) __Spouse __Parent __Other

RESPONSIBLE PARTY (GUARANTOR) INFORMATION

Last Name First Name

Address Apt#

Home Phone Work Phone Other Phone

City State Zip Code

__Cell __Pager __Fax

Middle Initial Nickname/AKA

EMERGENCY CONTACT

Primary Insurance ID Number Group Number Telephone Number

Secondary Insurance ID Number Group Number Telephone Number

Insured Member Social Security Number Date of Birth ID Number

INSURANCE INFORMATION

PHYSICIAN REFERRAL INFORMATION

For a total of 100%, what % is back pain and what % is leg? % Low Back Pain % Leg Pain

(i.e. 30% low back pain with 70% leg pain) + =100%

For a total of 100%, what % is neck pain and what % is arm? % Neck Pain % Arm Pain

(i.e. 20% neck pain with 80% arm pain) + =100%

9 Your level of pain from 0 to 10

0 1 2 3 4 5 6 7 8 9 10

ÅLess Pain Worse Pain Æ

Neck Pain

Right Arm Pain

Left Arm Pain

Low Back Pain

Right Leg Pain

Left Leg Pain

Using the symbols, mark the location and type of pain on the diagrams

If you have pain into the lower leg, feet, or hands, make sure you note it

RIGHT LEFT LEFT RIGHT

FRO

NT

BACK

Type of Sensation:

Stabbing/Burning: ^ Aching: X

Pins and Needles: - Numbness: O

9 Do you have: No Yes Explain where

Numbness in the arms/hands or legs/feet?

Weakness in the arms/hands or legs/feet?

9

Rest Laying flat

Sitting Walking on flat surfaces

Walking up stairs

Walking down stairs

Bending / twisting

Other (Describe)

Pain worse with

Pain better with

9 Do you have: No Yes

Loss of bowel control? (difficulty controlling/initiating bowel movements or incontinence)

Loss of bladder control? (difficulty controlling/initiating urination or incontinence)

Balance problems from leg weakness?

Balance problems not from weakness but from lack of coordination?

Problems handling small objects such as coins or problems buttoning your shirts?

9Treatment history

No

Yes

Details (If Yes)

9 Made my pain:

Better No Change Worse

Anti Inflammatory pain medicine (ie Motrin, Aleve)

Medication:

Narcotics (ie Vicodin, Percocet)

Medication:

Epidurals or Selective Nerve Root injections

How many: Date of last injection:

Physical Therapy How long:

Physiatrist (Pain Specialist) Name:

Acupuncture Name:

Chiropractor Name:

Medical history (ie: High blood pressure, asthma, high cholesterol, etc) � I have no medical problems

9Do you have history of cancer?

No Yes Details (If Yes)

Type: Prior treatment:

Surgical history (i.e.:Tonsillectomy, hip replacement, heart surgery, etc) � I have not had surgery in the past

Date of Surgery Surgery (Specify Right or Left side if relevant)

List ALL medications, vitamins, and supplements you are currently taking. (May attach list of medications) � I currently take no medications

Allergic reactions including medicines, iodine, intravenous dye, latex, shellfish, etc � I have no allergies

Medication/Substance Allergic Reaction

Occupational/Social history � I am currently retired

What is your occupation?

9 No Yes Details (If Yes)

Are you out of work due to your spinal condition? How long have you been out of work?

Do you have a workman’s compensation claim? Date of work injury:

Do you smoke cigarettes?

How many packs per day?

For how many years?

Do you smoke a pipe or cigars? How often?

Do you dip snuff or chew tobacco? How often?

Do drink alcohol? How many drinks per week?

Do you use any street drugs? Which drugs and how often?

Who do you live with?

Family history of disease � I have no family history of disease

Relationship Disease Relationship Disease

Review of systems 9 General 9 Eye,Ear Nose,Throat 9 Musculoskeletal 9 Psychiatric

Fever or Chills Difficulty swallowing Joint pains Anxiety Dizziness Hearing loss Muscle aches Depression Fainting spells Hoarseness Ankylosing spondylitis Psychiatric hospitalization Fatigue Nose bleeds Weak bones Panic attacks Frequent headaches Ringing in ears Rheumatoid arthritis Suicidal thoughts Insomnia Sinus problems Osteoarthritis Psychiatric drugs Sweats Blurry vision Bone cancer Memory loss Weight changes Poor vision Bone infections Other:

Other: Other: Other: 9 MEN only 9 Cardiovascular 9 Gastrointestinal 9 Genitourinary Breast lumps

Ankle swelling Poor appetite Bladder control Enlarged prostate Chest pains Bowel changes Blood in urine Erectile dysfunction

Enlarged heart Constipation Frequent urination Penis discharge Heart attack Diarrhea Kidney stones Prostate cancer Heart murmur Excessive thirst Painful urination Other:

Heart palpitations Heartburn Urgent urination 9 WOMEN only High blood pressure Nausea Weak stream Abnormal pap smear Shortness of breath Rectal bleeding Other: Breast lumps

Irregular heartbeat Stomach pain 9 Neurological Vaginal discharge Prolonged bleeding Ulcers Loss of motor control Severe menstrual pain

History of blood clots Vomiting Weakness Hot flashes

Other: Other: Paralysis All other ROS Negative 9 Endocrine 9 Skin Poor balance

Blood sugar problem Bruise easily Seizures Use of steroids Foot ulcers Speech difficulties Over active thyroid Rashes Tremors Under active thyroid Sores that won’t heal Muscle wasting Other: Other: Other:

Office Use Only Height Weight BP / Pulse

NOTICE OF PRIVACY PRACTICESThis notice describes how medical information about you may be used and disclosed, and how you can get access to this

Thr,rrMENTWe are permitted to use and disclose your medical information to those involvedin yourtreatment. For example,the physicianin this practiceisa specialist. When weprovidetreatment, we may request that your primary care physician share your medicalinformation with us. Also, wemay provide your primary carephysicianinformationabout your particular condition so that he or she can appropriately treat you for othermedical conditions, if any.

PryunNrWe are permitted to use and disclose your medical information to bill and collectpayment for the services provided to you. For example, we may complete a claim form toobtain payment from your insurer or HMO. This form will contain medical information,such asa description ofthe medical service provided to you, that your insurer or HMOneed to approve payment to us.

flnalru C,qnE OpnnanroNsWe are permitted to use or disclose your medical infbrmation for the purpose of healthcare operations, which areactivities that support this practiceand ensure that qualitycare is delivered. For example, we may ask another physician to review this practice"scharts and medical records to evaluate our performance so that we may ensure that onlybest health careis provided by this practice.

Drscr.osuREs Tuar Clx Br M.ron WrrHourYounAurHopttz,ATroNThere are situations in which we are permitted by law to disclose or use your medicalintbrmation without your written authorization, or an opportunity to object. ln othersituations we will ask for your written authorization before using or disclosing anyidentifiablehealth infbrmation about you. If you choose to sign an authorization todisclose information, you can later revoke that authorization, in writing, to stop firtureuses and disclosures. However, any revocation will not apply to disclosures or usesalready made or taken in relianceon that authorization.

AnnruroNAL Usns on DrscLosuRES. Public Health, Abuse or Neglect and Health Oversight. Legal Proceedings and Law Enforcement. Military, National Securityand Intelligence Activities, Protection of The President. Research, Organ Donation, Coroners, Medical Examiners,and Funeral Directors

Wonr<nns I CoMPENSATToNWe may disclose your medical information as required by the Texas workers'compensation law.

INu,lrnsIf you are an inmate or under the custody of law enforcement, we may release yourmedical infbrmation to the correctional institution or lawenforcement official. Thisrelease is permitted to allow the institution to provide you with medical care)to protectyour health or the health and safety of others, or fbr the saf'ety and securityof theinstitution.

RreurRED BY LAwWe may release your medical information where the disclosure is required by law.

Youn Rrcnrs Uuopn FuuBn.ql Pnrvncv RncuLATroNSThe United States Department of Health and Human Services created regulationsintended to protect patient privacy asrequired by the Health Insurance Portability andAccountability Act (HIPA A). Those regulations create several privileges that patientsmay exercise. We will not retaliate against a patient that exercises their HIPA A rights.

RneursrnD RnsrnrcrroNsYou may request that werestrict or limit how your protected health information is used ordisclosed fbr treatment, payment, or health care operations. We do NOT have to agree tothis restriction, but if we do agree, wewill comply with your request except underemergency circumsta nces.To requestarestriction, submit the followingin writing:(a) The information to be restricted, (b) what kind ofrestriction you are requesting (i.e. onthe use of information, disclosure of information or both), and (c) to whom the limitsapply. Please send the request to the address and person listed below.You may alsorequest that we limit disclosure to familymembers, other relatives, orclose personal fiiends that may or may not be involvedin your care.

Rnc u vI N G ffilFrImlrIAL C o vruuN I cATI oN s By ALTERNATTVE

MraNsYou may request that we send communications of protected health information byalternative means or to an alternative location. This request must be made in writing tothe person listed below. We are required to accommodate only reasonable requests.Please specify in your correspondence exactly how you want us to communicate with youand, ifyou are directing us to send it to a particular place, the contact/addressinformation.

fNspncrroN AND Coprns or PnorncrED flnelrHINnonMATroNYou may inspect and/or copy health information that is within the designatedrecordset, which is information that isused to make decisions about your care. Texas lawrequiresthat request fbr inspection of your health information alsobe made in writing.Please send your request to the person listed below.We can refuse to provide some of the information you ask to inspect or ask to becopied i fthe information :

' Includes psychotherapy notes' lncludes the identity of a person who

provided the information promise ofconfidentially

' ls subject to the Clinical Laboratory Improvements Amendments of 1988. Has been compiled in anticipation of litigation

We can refuse to provide access to or copies of some infbrmation for other reasons,provided that we provide a review of our decision on your request. Another licensedhealth care provider who was not involved in the prior decision to deny access willmake any such review. Texas law requiresthat we are ready to provide copiesor anarrative within 15 days of your request. We will inform you of when the records areready, or ifwebelieve access should be limited. Ifwe deny access, wewillinfbrm youin writing. HIPA A permits us to charge a reasonable cost based fee. T'he Texas StateBoard of Medical Examiners(TSBME) has set limits on fees tbr copiesofmedicalrecordsthat under some circumstances may be lower than the charges permitted byHIPA A. In any event, the lower of the fee permitted by HIPA A or the fee permittedbythe TSBME willbe charged.

AUnxDMENT oF Mnorclr fNronMATroNYou may request an amendment of your medical infbrmation in the designated recordset. Any such request must be made in writing to the person listed below. We willrespond within 60 daysofyour request. We may refuse to allow an amendment if theinformation:' Was not created by this practice or the physicians here in this practice' ls not part of the Designated Record Set' Is not available for inspection because of an appropriate denial. If the infbrmation is accurate and complete

Even ifwerefuse to allowan amendment you arepermitted to include a patientstatement about the infbrmation at issuein your medical record. If werefuse toallow an amendment we will inform you in writing. lf we approve the amendment,wewill inform you in writing, allowthe amendment to be made and tell others thatwe know havethe incorrect information

AccouNTrNGoF Cnnrarx f)rsclosuREsThe HIPA Aprivacy regulations permit you to request, and us to provide, an accountingof disclosures that are other than for treatment, payment, health care operations, ormade via an authorization signed by you or your representative. Please submit anyrequest for an accounting of disclosure to the person listed below. Your firstaccounting ofdisclosures (within a 12 month period) willbe free. For additionalrequests within that period we are perrnitted to charge forthe cost of providing the list. [f there is a charge we will notify you and you maychoose to withdraw or modify your request before any costs are incurred.

ApporNTMENr RnnnINDERS, ThnarMENT ArrnnNATrvES, ANDOrHnn flnarrH-RELATED BrNnnrrsWe may contact you by telephone, mail, or both to provide appointrnent reminders,information about treatment alternatives, or other health-related benefits and servicesthat may be of interest to you.

CouplArNTSlf you are concerned that your privacy rights havebeen violated, you may contact theperson listed below. You may alsosend a written complaint to the United StatesDepartment of Health and Human Services. We will not retaliate against you for filinga complaint with the government or us. The contact information fbr the United StatesDepartment ofHealth and Human Services is:

HIPAA Complaint7500 Security Blvd, C524-04

Baltimore, MD 21244

QunsuoNs AND Coxracr PnnsoN FoR RoeursrsIf you haveany questions or want to make a request pursuant to the rights describedabove, please contact:

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Thisnotice iseffective on the followingdate: April 14,2003. We may change ourpolicies and this notice at any time and have those revised policies apply to all theprotected health information we maintain. If or when we change our notice, wewill post the new notice in the oftice where it can be seen.

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATIONDeveloped for rexas Health & .*"r".#ffi:?lJ:i!?

Please read this entire form before signing and complete all thesections that apply to your decisions relating to the disclosureof protected health information. Covered entities as that term isdefined by HIPAA and Texas Health & Safety Code $ 181.001 mustobtain a signed authorization from the individual or the individual'slegally authorized representative to electronically disclose that indi-vidua!'s protected health information. Authorization is not required fordisclosures related to treatment, payment, health care operations,performing certain insurance functions, or as may be otherwise au-thorized by law. Covered entities may use this form or any otherform that complies with HIPAA, the Texas Medical Privacy Act, andother applicable laws. lndividuals cannot be denied treatment basedon a failure to sign this authorization form, and a refusal to sign thisform will not affect the payment, enrollment, or eligibility for benefits.

NAME OF PATIENT OR INDIVIDUAL

Last

OTHER NAME(S) USED

DATE OF BIRTH Month Day Year

First Middle

ADDRESS

CITY STATE- ZIP

PHONE (_)EMAIL ADDRESS (Optional) :

ALT. PHONE (_)

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTHINFORMATION:

REASON FOR DISCLOSURE(Choose only one option below)

Person/Organizatio n N ameAddressCity State Zip CodePhone (_-) Fax (--)WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?Person/Organization Name Adam Brrrggeman, MD _Address 2077n,1 lS 2R1 N #1n8. PMR 439city SmAnlon-i

WHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature ol a minorpatient is required for the release of some of these items. ll all health inlormation is to be released, then check only the lirst box.

E All health informationtr Physician's Orderstr Progress Notestr Pathology Reports

tr History/Physical Examtr Patient Allergiestr Discharge SummaryD Billing lnformation

Past/Present MedicationsOperation ReportsDiagnostic Test ReportsRadiology Reports & lmages

Treatment/Continuing Medical CarePersonal UseBilling or ClaimslnsuranceLegal PurposesDisability DeterminationSchoolEmploymentOther

Lab ResultsConsultation ReportsE KG/Cardiology ReportsOther

EItrtrtrtrDtrtrn

trtrDtr

trtrtrtr

Your initials are required to release the following information:Mental Health Records (excluding psychotherapy notes)Drug, Alcohol, or Substance Abuse Records

Genetic lnformation (including Genetic Test Results)H lV/Al DS Test Results/Treatment

EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; theing the age ol maiority; or permission is withdrawn; or the following specific date (optional): Month _ Day _RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this au-thorization to the person or organization named under 'WHO CAN RECEIVE AND USE THE HEALTH INFORMATION." I understand thatprior actions taken in reliance on this aulhorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures ol the inlormation as described. I un-derstand that relusing to sign this lorm does not stop disclosure ol health inlormation that has occurred prior to revocation or thatis otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provid-ed by Texas Health & Safety Code S 181.154(c) and/or 45 C.F.R. S 164.502(aX1). I understand that inlormation disclosed pursu-ant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

SIGNATURE XSignature of lndividual or Individual's Legally Authorized Representative DATE

Printed Name of Legally Authorized Representative (if applicable):lf representative, specify relationship to the individual: tr Parent of minor tr Guardian tr Other

A minor individual's signature is required lor the release of certain types of information, including for example, the release ol information related to cer-tain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.9., Tex. Fam.Code $ 32.003).

individual reach-Year

Signature of Minor lndividualSlGNATURE

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