Ryan Chiropractic, PLLC Christopher P. Ryan, DC Paul W. Ryan, DC Jennifer L. Stanton, DC Kenneth W. Padgett, DC MEDICAL INTAKE FORM Name_______________________ Family Physician/Internist: ______________________ MEDICAL INFORMATION: TO THE BEST OF YOUR KNOWLEDGE, DO YOU HAVE /HAVE HAD: Aneurysms Angina / Chest Pain yes yes no no Blood Clots yes no Blood Disorders Bruising yes yes no no Asthma Congestive Heart Failure Heart Murmur High Blood Pressure High Cholesterol Myocardial Infarction (heart attack) Pacemaker Peripheral Vascular Disease Raynaud’s Rheumatic Fever Stents Stroke TIA’s (mini stroke) yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no Sinusitis Ear Infections TMJ Cataract(s) Carpal tunnel syndrome yes yes yes yes yes no no no no no Allergies: Food yes no name_______________________ Medicine yes no name_______________________ Seasonal yes no Other yes no name_______________________ Bronchitis yes no Emphysema yes no Sarcoidosis yes no Shortness of Breath yes no Sinus Surgery yes no Sleep Apnea yes no Do you smoke?: yes no How long________years Circle packs/day: <1 1 >1 Abdominal Pain Vertigo/Meniere’s Disease yes yes no no Change in Appetite yes yes yes yes no no no no Cholecystitis Chroh’s Disease Glaucoma Psoriasis yes no Constipation Diarrhea Difficulty Swallowing Diverticulitis GERD Hepatitis Hiatal Hernia Irritable Bowel Syndrome Liver Disease Nausea Pancreatitis Ulcerative Colitis Ulcers Vomiting Hernia(Inguinal/Umbilical) Incontinence Kidney Disease Ovarian Cysts STD’s Urination: Blood Frequency Pain Multiple Sclerosis Numbness Arthritis Arthroscopic Surgery Back Injury(s) Back Surgery(s) Dislocations Thyroid Disease Anemia Vitamin B Deficiency yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no Sleeping Position: Side Back Stomach Fractures/Dislocation yes no Location_________________________ Gout yes no Joint Replacements yes no Lupus yes no Lyme Disease yes no Muscle Weakness yes no Neck Injury(s) yes no Neck Surgery(s) yes no Osteopenia yes no Rheumatoid Arthritis yes no Sjogren’s Syndrome yes no Swollen Joints yes no Systemic Lupus Erythematosus yes no Tremors yes no Bell’s Palsy yes no Scleroderma yes no Skin Rash yes no Kidney Stones yes no Headaches: Cluster yes no Migraine yes no Muscle Tension yes no Head Injuries yes no Loss of Consciousness yes no HIV/AIDS Seizures Vertigo/Dizziness Visual Changes Diabetes (Juvenile/Adult) yes yes yes yes yes no no no no no Fibromyalgia Leukemia Scoliosis yes yes yes no no no Retinal Detachment Lupus Tumor(s) (Malignant or Benign) History of Chemo or Radiation Alcoholism Drug Addiction Metal Fragments in Body History of MVA’s History of Trauma Female: Abnormal Periods Breast Lumps Last Breast Exam Date__________ Menopause-Post Currently Pregnant C-section Male: Vasectomy Prostate Cancer yes yes yes yes yes yes yes yes yes no no no no no no no no no yes yes no no yes yes yes no no no yes yes no no Height_________ Weight_________ Any Family History of the following: High Blood Pressure yes no Rheumatoid Arthritis yes no Diabetes yes no Heart Problems yes no Cancer yes no Arthritis yes no Back Surgery yes no Breast Cysts Breast Cancer Tubal Ligation Hormone Replacement Children #______ Uterine Fibroids yes yes yes yes yes yes no no no no no no Prostate Hypertrophy yes no last prostate exam____________ Previous Chiropractic Care: yes no Exercise Weekly: yes no Hospitalizations Include Year:___________________________________________________ Xrays/ MRI/ CT Scans: Include Year and location:____________________________________ List of Current Medications: ______________________________________________________ ______________________________________________________________________________ Surgeries: Circle or list: Hysterectomy Heart Bypass Cholecystectomy Tonsillectomy Appendectomy Sinus Cataract Lasix Hiatal Hernia Inguinal Hernia Biopsy Skin Cancer Carpal Tunnel Hip Replacement L R Both Knee Replacement L R Both Back Surgery Neck Surgery Other_________________________________________________________________