• CAGEN

    Assessment Document Specifications

      Written Blueprint

      Case Topics

      Tools and Modalities

      Written Exam Case Template

      References

      Practical Blueprint

      ACNB Practical Examination Case Template

      Sample Case History Flow Chart

    Introduction

    This is an exam blueprint, also referred to as, exam specification for American Chiropractic Neurology Board’s certification exam in functional neurology. The skills and knowledge certified by this examination represent a postdoctoral chiropractic level of expertise where a certified individual can:

    1. Examine individuals with a thorough functional neurological examination
    2. Diagnose neurological and associated problems after examination
    3. Treat through chiropractic methodologies neurological and associated problems
    4. Treat through functional and environmental modalities neurological and associated problems
    5. Educate patients with respect to minimizing chronic neurologically related problems


    Exam Purpose


    This examination is based upon the most critical job activities a Chiropractic Neurologist performs. The skills and knowledge certified by this examination represent entry level into the postdoctoral chiropractic neurological professional level of expertise for a certified individual. The critical job activities derived from the 2002 job analysis of Chiropractic Neurologists include the following patient care areas:

    1. Examination
    2. Diagnosis
    3. Treatment
    4. Follow-up

    Additionally, ethics and techniques were identified by our Subject Matter Expert (SME) Panel as important components not included on the 2002 job analysis. Questions asked of the Board by the public and Diplomates were also brought to the SME panel and this data supported the inclusion of ethics and techniques on the exam. The panel divided the neuraxis into the twelve domains sited below and identified as critical in the job analysis.


    Background and Experience


    The test is intended to address the knowledge and skill areas that demonstrate proficiency as a Chiropractic Neurologist. Eligibility requirements are:

    1. The applicant must hold the degree of Doctor of Chiropractic from a CCE accredited college (USA) or its equivalent.

    2. The applicant must show evidence of having successfully completed a post doctoral program in neurology of three hundred (300) credit hours from a chiropractic college, university, institution, foundation or agency whose program is approved by the continuing education committee of the Commission for the Accreditation of Graduate Education in Neurology (CAGEN). The Chiropractic College, organization, institution, foundation, or agency from which the applicant has completed his/her course of study must certify to the Board that the applicant has satisfactorily completed three hundred (300) credit hours of postdoctoral instruction in neurology.

    3. The applicant must possess a license or registration to practice chiropractic and be in good standing with the respective licensing/registration agency.

    The skills and knowledge measured by this examination are derived from current course content and from an understanding of the jobs of current Chiropractic Neurologists. A team of highly qualified Chiropractic Neurologists defined the test content and determined the categories for case submission for the exam.


    Exam Structure

    The knowledge domains measured by this examination are shown in the table below along with the percentages of the exam that are applied to each domain.  This is in accord with the job analysis update from the Subject Matter Experts performed in 2007.

    Domains

    Percentage of Exam

    Brain and Its Environment
    5.78%
    Lobes of the Brain
    6.44%
    Brain Stem & Cranial Nerves
    8.44%
    Spinal Cord
    7.56%
    Peripheral Nerves
    13.44%
    Autonomic Nervous System
    5.11%
    Cerebellum & Vestibular System
    14.44%
    Basal Ganglia & Limbic System
    7.33%
    Muscles / NMJ and Receptor Disease
    8.00%
    Sensory
    7.78%
    Neuro Endocrine
    7.33%
    Neuro Anatomy & Physiology 7.56%
    Ethics
    1.11%


    Objectives:

    The objectives for the examination as determined from the job analysis and its update are as follows:

    Objectives

    Percentage of Exam

    General Knowledge
    5.11%
    Pathways
    12.00%
    Diagnosis (Clinical, Level of Lesion & Functional)
    30.44 %
    Differential Diagnosis
    15.11%
    Treatment (Adjustment and other treatments)
    13.33%
    Rehabilitation
    4.44%
    Follow-up
    0.44%
    Metabolic Rate
    1.78%
    Risk Factors
    4.22%
    Referral
    3.78%
    Special Studies
    7.56%
    Techniques
    0.67%
    Ethics
    1.11%

    According to the job analysis update, diagnosis and differential diagnosis are the most significant portions of the job of the chiropractic neurologist.  Treatment, of course, follows those.  The reason that diagnosis is weighed so heavily is because each patient receives three types of diagnosis:  clinical/medical, level of the lesion, and functional.  In this way, the chiropractic neurologist differs from other diagnostic professions because the level of the lesion and the functional diagnoses are the ones that dictate the treatment and rehabilitation modalities and the mechanisms for measuring success of treatment.

    All questions on the written examination are multiple-choice.  Some are complex or multiple-multiple choice questions.  A Scantron sheet is used for the recording of answers.

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    Domain 1.0 Brain & Its Environment
    Kennedy Syndrome Kennedy
    Aneurysm (Berry Aneurysm) Aneurysm
    Cortical Neoplasm
    Pseudotumor Cerebrii
    Middle Cerebral Artery stroke (lenticulostriate branch)
    Bacterial Meningitis / Viral Meningitis
    Epidural Hematoma
    Parasagittal Meningioma
    Cavernous Sinus Thrombosis
    Senile Dementia / Alzheimer's
    Cluster headache
    Migraine
    Anterior Cerebral Artery Stroke
    Posterior Cerebral Artery Stroke
    Pituitary Adenoma
    Middle Cerebral Artery stroke (Main trunk occlusion)
    Capsular CVA
    CVA to the dominant or the non-dominant hemisphere
    Pineal Tumor with hydrocephalus P

    Domain 2.0 Lobes of the Brain Lobes
    Traumatic Head Injury
    Carotid Artery Occlusion
    Schizophrenia
    Auditory Processing for Language (Different Aphasia's)
    Multiple Sclerosis
    Addiction
    ADHD / ADD: frontal lobe-cingulate gyrus
    Subarachnoid haemorrhage
    Temporal Lobe Automatism
    Dysphasic Confusion
    Anxiety / Panic Attacks
    Depression (Various types)
    Complex Partial Seizures
    Autism
    Dyslexia
    Nocturnal Enuresis
    Hemsiphericity
    Cerebral Palsy
    Coma

    Domain 3.0 Brain Stem & Cranial Nerves
    Brainstem Ischemia (TIA)
    IVth ventricle tumor -Bell's palsy & lat rectus palsy IVth
    Dysphagia
    Bell's Palsy (Facial Paresis) (Upper verses Lower)
    Acoustic Neuroma
    Dysarthria
    Foville's/Parinaud's syndrome
    Post comm art aneurysm
    Benedikt's Syndrome
    Weber's syndrome
    Millard-Gubler Syndrome
    Locked In Syndrome
    Nothnagel's Syndrome
    Trigeminal Neuralgia

    Domain 4.0 Spinal Cord
    Cervical Myelopathy
    ALS
    Anterior Spinal Artery Syndrome
    Ventral Cord Pathology
    Poliomyelitis
    Cervical Stenosis
    Cauda Equiina Syndrome
    Syringomyelia / Syringobulbia
    Tabes Dorsalis
    Acute Transverse Myelitis
    Friedreich's Ataxia
    Sub acute Combined Degeneration
    Caudication of the Cauda Equina
    Lumbar disc hernation at T12 affecting the conus from within
    Progressive Muscular Atrophy
    Facet Syndrome
    Ankylosing Spondylitis
    Tension Headache
    Familial Spastic Paraplegia

    Domain 5.0 Peripheral Nerve
    Upper Brachial Plexus (Erbs palsy)
    Lower Brachial Plexus (Pancoast's tumor)
    Radial Entrapment (Spiral groove lesion)
    C6 Radiculopathy (Due to neural foraminal stenosis,
    spondylosis)
    Diabetic Neuropathy (Stocking glove, sensory > motor)
    Median Nerve Entrapment (Pronator Teres)
    Cubital Tunnel
    L5 Radiculopathy (Due to a disc herniation)
    Charcot Marie Tooth (Inherited neuropathies)
    Arthritic related neuropathy (Rheumatoid Arthritis)
    Thyroid Related Peripheral Neuropathy
    Autoimmune Related Neuropathy (Sulfatide / MAG / GM1 /
    Gallop)
    CIDP (Chronic demyelinating disorder)
    Neuralgic Amyotrophy
    Peroneal Nerve Lesion at the Fibular Head
    Peripheral Nerve Pathology due to Vasculitis
    Anterior Interosseus Lesion
    Ulnar Nerve lesion at Guyons Canal
    Sciatic Nerve lesion due to Injection Depo
    Amyloid Neuropathy
    Lead / Arsenic Induced Neuropathies
    Alcohol Induced Neuropathy
    Tarsal Tunnel Syndrome

    Domain 6.0 Autonomic Nervous System ANS
    Migraine (Trigeminal Mechanism)
    Cardiac Arythmias/rate anomalies
    Horner's Syndrome
    Sympathetic Hypertonia
    Excess Mesencephalic Depolarization
    Vasovagal Response
    Raynauds
    Bergers
    Chronic Regional Pain syndrome (RSD)
    Postural Hypotension
    Autonomous Bladder (subsacral Lesion)
    Uninhibited Bladder
    Erectile Dysfunction
    Hypertension

    Domain 7.0 Cerebellum & Vestibular System C&VS
    Benign Positional Vertigo
    Vermal Lesions
    Cerebellar Ataxia
    Meniere's
    Cerebellar Atrophy/malacia
    Vertebral Artery Syndrome
    Cervicogenic Vertigo
    Fistula
    Vestibular epilepsy
    INO
    Wallenberg Syndrome
    Basilar Ischemia
    Cupulolithiasis
    TND Cerebellum
    Intention Tremor
    Skew Deviation
    Exotropia
    Peripheral Vestibular Neuronitis

    Domain 8.0 Basal Ganglia & Limbic System BG-LS
    Parkinson's
    Tourettes
    Hemiballism
    Panic Disorder
    Anxiety
    Dystonia/Essential tremors
    Insomnia
    Medication Induced Physiological Tremor
    Wilson's Disease (Copper induced athetosis)
    Sydenham's Chorea (Rheumatic fever induced movement
    disorder)
    Narcolepsy
    OCD
    Manic Depression

    Domain 9.0 Muscles/NMJ and Receptor Disease
    Hypertonicity (Spastic Gait) UMN lesion
    LMN lesion vs. UPN
    Duchenne's muscular dystrophy
    Myotonia Congenita
    Polymyositis
    Myesthenia Gravis
    Myotonic Dystrophy
    Radiculopathy vs nerve compression
    Limb Girdle Dystrophy
    Facioscapulohumeral Dsytrophy
    Botulism
    Tick Paralysis
    Sprain / Strain Injury
    Subluxation
    Whiplash
    Fibromyalgia
    Chromic Fatigue Syndrome
    Lambert Eaton Syndrome

    Domain 10.0 Sensory
    Conductive Hearing Loss
    Cortical Blindness
    Visual Distortion: superior temporal orbital tumor resulting in
    astigmatism
    Tinnitus
    Sensory Radiculopathy
    Guillian Barre syndrome
    Allodynia
    SNHL (Sensory Neural Hearing loss)
    Hyperalgesia
    Scotoma

    Domain 11.0 Neuro Endocrine
    Pituitary Adrenal Cortico Axis
    Hypothyroidism and neurological symptoms
    Hyperthyroidism and neurological symptoms
    Acromegaly (Growth Hormone Related Problems)
    sleep disorders (Sleep apnea) (Pineal and Melatonin)
    Eating Disorders (Anorexia Nervosa / Bolemia / Obesity)
    Irritable Bowel Syndrome
    Insulin Resistance / Hypoglycemia
    PMS

    Domain 12.0 Neuroanatomy & Physiology
    Diplopia & Ptosis - DDx myasthenia from III nerve palsy
    L5 radiculopathy -denervation mechanism (Acute verses
    Chronic)
    mild dementia 2o to hip fracture
    Sat night palsy - ischemic radial palsy
    Carpal tunnel in Type 2 Diabetic - mechanisms
    Otitis media induced Bell's palsy
    Diabetic lumbar (ischemic) plexopathy
    Vertigo/anosmia 2o to basal skull Fracture (possibly 2 cases)
    Hypocalcemia (carpal pedal spasms due to kidney disease
    Hypokalaemia
    Hyperkalaemia
    Parathyroid Disease
    Oxidative Stress
    Antioxidants / CoQ10
    Glutathione and Degenrative Neurological Disease
    Heavy Metal Exposure
    Hyponatremia
    Hypernatremia
    Mechanism of manipulation
    Slow stretch verses fast stretch

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    Tools used in Examination

    Special Test

    Risk Factors

    Treatment Tools

    Nutrition and
    Supplements

    Pen Light
    Pin Wheel
    Reflex Hammer
    Optokenetic Tape
    Ophthalmoscope
    Otoscope
    Sphymomanometer
    Stethoscope
    Thermometer
    Blind Spot
    Tuning fork
    SPO2
    Measuring Tape
    Novel Face Recognition
    Height/Weight Chart
    Cotton Balls         
    Scales

    X-Ray
    MRI
    CT Scans
    Sereology
    Electrolytes
    Blood Chemistries
    UA
    Glucose Tolerance
    NVC
    EMG
    Real Eyes
    VNG
    Spirometry

    Osteoporosis
    Unstable vertebral segments
    Fragile metabolic rate
    Diabetic
    Compression fx
    Demyelinating disease
    Chronic illness
    Coronary or carotid artery
         Blockage
    Prescription med side effects

    Hemi-field glasses
    Optokenetic Tape
    Jucussi
    Resistance exercise
    bands
    Arm Cables
    Spin chair
    Spin video
    Interferential TENS
    Caloric-warm/cold
    Traction
    G-five
    Exercise Equipment
    Puzzles
    Music
    Ultrasound
    Metronome
    Hemifield tape  

    Co-Q-10
    Vit C
    Vit E
    Calcium
    Potassium
    Omega 3 Fatty Acids
    Glucosamine
    Chondroiton
    Heavy Water
    Antioxidants
    Probiotics
    Detox products
    Chealation

     

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    HISTORY:

    Chief Complaint/Present Illness

    Pain History
    Family History
    Social History
    Past Medical History/Review of Systems

    PHYSICAL EXAM:

    General Appearance

    Vitals
    Height/WT; Temp; HR & Rhythm; Respiratory; B/P  L and R. Ausculatory Exam:    (Bruits, Lung Sounds, Abdominal Sounds); Pulses:  (Brachial, radial, femoral, popliteal, dorsalis pedis); Rib Excursion
    Mental Status
    Cranial Nerves
    Sensation
    Motor:  
    Tone: Strength: Reflexes
    Coordination/Balance
    Imaging/Special Studies: 

     

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    The following is a list of references used in preparation of the examination and to determine model answers.

  • Adams, R.D. and Victor, M. (Latest edition) Principles of Neurology. New York: McGraw-Hill Book Co.
  • Annals of Neurology, (Journal). Little Brown & Company
  • Barr, M.L. and Keirnan, J. A. The Human Nervous System: An Anatomical Viewpoint (Latest edition). Philadelphia: Harper & Row, Publishers.
  • Beatty, J. (1995) Principles of Behavioral Neuroscience. Time Mirror.
  • Blume, Warren T. (1994) Atlas of Adult Electroencephalography. Raven Press
  • Carpenter, M.B. Core Text of Neuroanatomy (Latest edition). Baltimore: Williams & Wilkins, Co.
  • Chiappa. Evoked Potentials in Clinical Medicine
  • Conn, P. Michael (1994) Neuroscience in Medicine. J.B. Lippincott.
  • Creutzfeldt, O. et.al. (1995) Cortex Cerebri: Performance, structural and functional organization of the cortex.
  • DeArmond, S.J., Fusco, M.M. and Dewey, M.M. Structure of the Human Brain. Structure of the Human Brain: A Photographic Atlas. (Latest edition). New York: Oxford University Press.
  • Dejong, R.N. The Neurologic Examination (Latest edition). Hagerston (MD): Harper and Row, Publishers.
  • Dyck, Peripheral Neuropathy.
  • Guyton. Textbook of Medical Physiology (Latest edition).
  • Haines, D. Neuroanatomy: An Atlas of Structures, Sections and Systems. (Latest edition). Baltimore: Urban & Schwarzenberg.
  • Heimer, L. The Human Brain and Spinal Cord: Functional Neuroanatomy and Dissection
  • Guide (Latest edition). New York: Springer-Verlag.
  • Jennes, Lothar, et.al. (1994) Atlas of the Brain, with medical correlations. Lippincott.
  • Joynt. Clinical Neurology. Lippincott: updated yearly.
  • Leigh, John R. & Zee, David S., 1999.  Neurology of Eye Movements (Contemporary). New York:  Oxford University Press.
  • Kandel, E.R., Schwartz, J.H. and Jessell, T.M. Principles of Neural Science (Latest edition). New York: Elsevier Science Publishing Col, Inc.
  • Kimura. Electrodiagnosis
  • Langman, J. Medical Embryology. (Latest edition). Baltimore: Williams & Wilkins.
  • Michaels (1994) The Cognitive Neurosciences. Gazzaniga (ed). MIT Press
  • Mosenthal, W.T. (1994) A Textbook of Neuroanatomy with Atlas and discussion guide. Parthenon.
  • Pryce-Phillips, William (1995) A Companion to Clinical Neurology. Little, Brown & Co.
  • Segev, Idan (ed), et.al. (1995) The theoretical foundation of Dendritic Function: selected papers of Wilfrid Rall with commentaries. MIT Press.
  • Theodore, William (ed) et.al. (1995) Epilepsy: 100 elementary principles. (3rd Edition) W.B. Saunders.
  • Yatsu, Frank M., et.al. (1994) Stroke (100 Maxims in Neurology Series). Hodder & Stoughton.
  • Recent Additions:

    Author                                     Book/Article/Presentation                                     ISBN/Journal

    Blume, Warren T.Atlas of Adult Electroencephalography                         3-936817-15-4

    Brock, JB Board Review Presentation (found in Carrick Course Companion)

    CarrickClinical Neuroscience Course                                     Companion Guide I & II

    DeMyerTechnique of the Neurologic Examination, 5th Ed. 71405682

    Kandel, Schwartz & Jessel.Principles of Neural Science, 4th Ed                               838577016

    NolteThe Human Brain                                                               323013201
    (An Introduction to It's Functional
    Anatomy) 5th Ed.

    Patten                                     Neurological Differential Diagnosis, 2nd Ed.                         3540199373

    Preston & Shapiro                        Electromyography & Neuromuscular                              075067492X
    Disorders, 2nd Ed.

    Theodore, William                        Epilepsy: 100 elementary principles. (3rd Ed.)             702018139
    (ed) et.al.

    Yatsu, Frank M.,                         Stroke (100 Maxims in Neurology Series)                           BMJ
    et. al.                                                                                                                                                1995;311:69
    (1 July)

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    Introduction:

    This is an exam specification for the Practical Exam in Chiropractic Neurology.  The skills and knowledge and abilities certified by this examination represent a professional level of expertise where the certified individual can:

    • Demonstrate the interview and psychomotor skills necessary in history taking and patient examination
    • Identify normal and abnormal findings from a physical/neurological examination

    Exam Purpose:

    This examination is based upon the most crucial job analysis activities a chiropractic neurologist performs.  The psychomotor skills, knowledge and abilities certified by this examination represent a professional level of expertise for a certified individual.  The critical job activities of a chiropractic neurologist are:

    • Demonstrate the capability of taking a patient history through the use of interview techniques
    • Demonstrate the psychomotor skills of performing a physical/neurological examination on a patient
    • Demonstrate the ability to accurately identify the findings of a physical/neurological examination through the use of video clips of examination results

     

    Background and Experience:

    The test is intended to address the knowledge and skill areas that demonstrate proficiency as a Chiropractic Neurologist.  Eligibility requirements are:

    • The applicant must hold the degree of Doctor of Chiropractic from a CCE accredited college (USA) or its equivalent.
    • The applicant must show evidence of having successfully completed a post doctoral program in neurology of three hundred (300) credit hours from a chiropractic college, university, institution, foundation or agency whose program is approved by the continuing education committee of the Commission for the Accreditation of Graduate Education in Neurology (CAGEN). The Chiropractic College, university, organization, institution, foundation, or agency from which the applicant has completed his/her course of study must certify to the Board that the applicant has satisfactorily completed three hundred (300) credit hours of postdoctoral instruction in neurology.
    • The applicant must possess a license or registration to practice chiropractic and be in good standing with the respective licensing/registration agency.

     

    The skills and knowledge measured by this examination are derived from current course content and from an understanding of the jobs of current Chiropractic Neurologists.  A team of highly qualified Chiropractic Neurologists defined the test content and determined the categories and videoed examination findings for the video clips for the exam.


    Exam Structure:

    The knowledge domains measured by this examination are shown in the table below.

    Domains
    History
    Physical/Neurological Examination
    Examination Finding

    Within the domains, the following table identifies the test objectives.  Test items will relate to a specific objective within a domain.

    History Percentage
    Onset, Timing, Site Involved, Radiation, Quality/Characteristics, Palliative/Aggravating Factors (OPQRST) 10%
    Past HX; Trauma, Surgeries, etc. 5%
    Social HX 5%
    Family HX 5%
    Review of Systems 5%
    Examination
    Vital Signs: 5%
    Cranial Nerves 6%
    Sensory 6%
    Motor 7%
    Cerebellar/Balance 6%
    Cardiovascular/Provocative Maneuvers 10%
    Simulation Findings  
    Reflexes 2%
    Gait 2%
    Eye Movements 2%
    Provocative Tests 2%
    Cerebellar tests- dysdiadochokinesis-dysmetria, etc. 2%
    Motor/Strength Tests 2%
    Tone (ptosis, facial paresis, etc) 2%
    Pupil responses 2%
    Palatal Paresis, Gag Reflex 2%
    Posture & angulation & tongue deviation 2%
    Spontaneity of movement 2%
    Observation (atrophy, sweating, edema, color, atrophic skin changes) 2%
    Recognition/sequencing tests 2%
    Parietal Drift 2%
    Percussion Myotonia, clonus 2%


    The answers to the questions on the video simulations are oral.  The candidate will hear and read the questions, then respond orally.  This section is also videotaped.

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    The candidate must be able to conduct a thorough history:

    OPQRST
    Past History-thorough
    Social History
    Family History-1st and 2nd degree relatives
    ROS-Every System

    The candidate must be able to demonstrate the psychomotor skills and the knowledge to perform a complete head-to-toe Neurological Physical Examination:

    Vital Signs:  Ht/wt, Temperature, Pulse, Respirations, Blood Pressures (Bilateral)
    Cranial Nerves:  ALL and all aspects of testing each one

    Sensory:  Pain & Temperature, Vibration and Light Touch, Joint Position Sense of ALL extremities

    Motor:  Reflexes, Tone, All extremities

    Coordination/Balance:  Romberg, Finger-Nose, Rapid alternating movements, pronation/supination, Gait & Tandem, Heel-Shin test.  Be certain to perform all tests correctly and safely.

    Heart/Lung:  Auscultation of all heart sounds and areas, auscultation for bruits, auscultation of six (6) lung fields and apex, Palpation of pulses-upper and lower extremities

    Abdomen:  Auscultation of each quadrant and abdominal aorta; percussion of each quadrant, palpation of each quadrant (in this order)

    Correctly perform special neurological and orthopedic tests such as:  Optokinetics, Eply’s, Hall Pike, Homan, Lhermitte’s, Hoffman’s, Tromner’s, TOS, Mill’s, Cozen’s, S.I. Joint ortho tests, A.C. joint pathology, ACL, Hip capsule, Tinel’s, Kemp’s, O’Donohues, and others.  This is NOT an exhaustive list.

    Video Clips:

    The candidate must be able to view a series of video clips of a neurological examination section (very short) and identify what he/she is seeing and what it means, including the nerves involved.  The candidate will be asked two questions about each of the 15 clips.  The questions are in an oral and written presentation format.  Each clip may be viewed a maximum of two (2) times.

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    Patient Name: _____________________________________________________
    Home Address: _____________________________________________________
    Home Phone: _____________________________________________________
    Work Phone: _____________________________________________________
    Date of Birth: _____________________________________________________
    Age: ___________
    Male: ___ Female: ___
    Marital Status: Single: ___ Married: ___ Separated: ___ Divorced: ___ Widowed: ___
    Occupation: _____________________________________________________
    Referring Physician’s Name: _____________________________________________________
    Type of doctor who referred you: _____________________________________________________
    State your major problem/pain: _____________________________________________________
    Describe your symptoms in detail. _____________________________________________________
    How long have you had this condition? _____________________________________________________
    Have you had similar conditions in the past?
    No: ___
    Yes: ___ If Yes, please specify: _____________________________________________________
    What activities aggravate your condition? _____________________________________________________
    Is this condition interfering with: Work: ___ Sleep: ___ Daily Routine: ___
    Other: _____
    Please specify: _____________________________________________________
    What other health care have you received for this problem, i.e. what other doctors have treated this condition? _____________________________________________________
    Other complaints: _____________________________________________________
    Do you presently take any medication/over the counter/homeopathic or recreational drugs? No: ___ Yes: ___ If Yes, please specify: _____________________________________________________
    _____________________________________________________
    List previous injuries/major illnesses/accidents _____________________________________________________
    _____________________________________________________
    List fractures/dislocations/concussions past and present: _____________________________________________________
    _____________________________________________________
    List previous surgeries/hospitalizations: _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    Have you had changes in bowel/bladder/sexual function? If so, please specify.
    _____________________________________________________
    _____________________________________________________
    Do you have any condition involving your heart/lungs/thyroid/or other internal organs? If yes, please specify: _____________________________________________________
    _____________________________________________________
    Are you a: Non-smoker: ___ Smoker: ___ (# of Packs per day _____ for ____ years) Ex-smoker: ___ (for how long ____).
    Regarding alcohol use, are you a: Never Drank: ___ Drinker: ___ Ex-drinker: ___
    If you drink alcohol, enter the average number of drinks per weeks:
    Bottles of beer: ____ Mixed drinks: ______ Glasses of wine: ____
    Shots of liquor: _____
    How would you rate the amount of physical activity you perform?
    Very little: ___ Little: ___ Moderate: ___ Active: ___ Very Active: ___
    List activities in which you participate on the average of two times per week:
    _____________________________________________________
    Please specify any conditions or illnesses in your family medical history (i.e. diabetes, cancer, etc.) (parents, grandparents, siblings, and children) _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    Females Only:
    Date your last menstrual period began: _____________________________________________________
    Number and ages of your children: _____________________________________________________
    Are you pregnant now? No: ___ Yes: ___ Not sure: ___
    Date of last pelvic/breast (PAP test) examination: _____________________________________________________
    _____________________________________________________
    Doctor’s Comments from the interview:
    _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    _____________________________________________________
    _____________________________________________________

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