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_________________________________________________________________