The doctor and staff of Ryan Chiropractic Clinic P.A. welcome you and want to provide you with the best possible care. We will conduct a thorough history and physical examination to decide if we can assist you. If we do not believe that your condition will respond to chiropractic care, we will not accept you as a patient but will refer you to the appropriate health care provider.
Please provide us with the following information.

Name ____________________________________________________________________      Date:  ___________________________
                               (last)                                               (first)                                                (middle)
Address_____________________________________________________________   Phone ___________________________
									                 
City _______________________________________  State___________________    Zip Code _________________________

Date of Birth ________/___________/__________   Married _______  Single _______  Number of Children _______________

Occupation or Profession _________________________________________________  Email___________________________

Employed By ______________________________________________________  Business Phone ______________________

Name of Head of Family __________________________________________________________________________________ 

Employed by ______________________________________________________   Business Phone ______________________

Doctor or friend who referred you to our office? __________________________________

Do you have health insurance? ______________  What Company? _______________________________________________

Social Security No. ________________________  Who is responsible for the account? _______________________________

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	Severity of Pain
List region of pain and circle severity number. (1 = least,  10 = greatest)

Ex___________neck__________________
1   2   3   4   5   6   7   8   9   10

MARK PAIN AREA
    Burning
000   Stabbing
----     Sharp
III       Achy
***       Numbness

1.__________________________________
1   2   3   4   5   6   7   8   9   10
2. _________________________________
1   2   3   4   5   6   7   8   9   10
3. _________________________________
1   2   3   4   5   6   7   8   9   10
4. _________________________________
1   2   3   4   5   6   7   8   9   10	
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1

1. Is today's problem caused by: 	□ Auto Accident	    □ Workman's Compensation

2. How often do you experience your symptoms?
	□ Constantly (76-100% of the time)		□ Occasionally (26-50% of the time)
	□ Frequently (51-75% of the time)		□ Intermittently (1-25% of the time)
3. How are your symptoms changing with time?
            □ Getting Worse		□ Staying the Same		□ Getting Better

4. How much has the problem interfered with your work?
           □ Not at all	        □ A little bit	   □ Moderately	   □ Quite a bit	   □ Extremely

5. How much has the problem interfered with your social activities?
□ Not at all	□ A little bit	□ Moderately	Quite a bit	□ Extremely

6. Who else have you seen for your problem?
□ Chiropractor		□ Neurologist		□ Primary Care Physician
□ ER physician		□ Orthopedist		□ Other:_____________
□ Massage Therapist	□ Physical Therapist	□ No one

7. How long have you had this problem? ___________

8. How do you think your problem began?
___________________________________________________________________________________

9. Do you consider this problem to be severe?
□ Yes		□ Yes, at times		□ No

10.  What aggravates your problem?
____________________________________________________________________________________
11.  Does anything relieve the pain?
____________________________________________________________________________________

12. What concerns you the most about your problem; what does it prevent you from doing?
____________________________________________________________________________________

13. What is your:  Height___________ 	Weight _____________	

14. How would you rate your overall Health?
□ Excellent         □ Very Good         □ Good         □ Fair         □ Poor

15. What type of exercise do you do?
□ Stenuous            □ Moderate            □ Light            □ None

16. Indicate if you have any immediate family members with any of the following:
□ Rheumatoid Arthritis                                       □ Diabetes                            □ Lupus
□ Heart Problems                                               □ Cancer                               □ ALS

17.  For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past.  If you presently have a condition listed below, place a check in the "present" column.
Past  Present			Past   Present		                                  Past   Present
□         □   Headaches		□          □     High Blood Pressure     		        □         □    Diabetes
□         □   Neck Pain		□          □     Heart Attack 	            		        □         □    Excessive Thirst
□         □   Upper Back Pain	□          □    Chest Pains	                                     □         □    Frequent Urination
□         □   Mid Back Pain		□          □    Stroke		                                     □         □    Smoking/Tobacco Use
□         □   Low Back Pain		□          □    Angina		                       □         □    Drug/Alcohol Dependance
□         □   Shoulder Pain		□          □    Kidney Stones	            		         □         □   Allergies
□         □   Elbow/Upper Arm Pain	□          □    Kidney Disorders	                       □         □   Depression
□         □   Wrist Pain		□          □    Bladder Infection	           	         □         □   Systemic Lupus                                                          
□         □   Hand Pain		□          □    Painful Urination	                       □         □   Epilepsy
□         □   Hip Pain		□          □    Loss of Bladder Control                	         □         □   Dermatitis/Eczema/Rash
□         □   Upper Leg Pain		□          □    Prostate Problems                       	         □         □   HIV/AIDS
□         □   Knee Pain		□          □    Abnormal Weight Gain/Loss
□         □   Ankle/Foot Pain		□          □    Loss of Appetite	                 For Females Only
□         □   Jaw Pain		□          □    Abdominal Pain	                    □         □     Birth Control Pills
□         □   Joint Pain/Stiffness	□          □    Ulcer		                         	      □         □     Hormonal Replacement
□         □   Arthritis			□          □   Hepatitis	                        	      □         □     Pregnancy
□         □   Rheumatoid Arthritis	□          □   Liver/Gall Bladder Disorder
□         □   Cancer			□          □   General Fatigue
□         □   Tumor			□          □   Muscular Incoordination
□         □   Asthma			□          □   Visual Disturbances
□         □   Chronic Sinusitis		□          □   Dizziness
□         □   Other:____________________________

18. List all prescription medications you are currently taking:
_______________________________________________________________________________

19. List all of the over-the-counter Medications or Vitamins you are currently taking:
________________________________________________________________________________

20. List all surgical procedures you have had:
________________________________________________________________________________

21. What activities do you do at work?
□ Sit:	        		□ Most of the day                      □ Half the day                 □ A little of the day
□ Stand:       		□ Most of the day                      □ Half the day                 □ A little of the day
□ Computer work:	□ Most of the day                      □ Half the day                 □ A little of the day
□ On the phone:		□ Most of the day                      □ Half of the day             □ A little of the day

22. What activities do you do outside of work?
_________________________________________________________________________________

23. Have you ever been hospitalized?	□ No	□ Yes
                                     if yes, why __________________________________________________________________________

24.   Have you ever had x-rays taken?    □ No    □ Yes   When? ________________________ By Whom? _______________

25. Have you had significant past trauma?     □ No       □ Yes  __________________________________

26. Anything else pertinent to your visit today?______________________________________________

27. Have you ever had a chiropractic treatment before?   □ No   □ Yes   Doctor’s Name ____________________________

      How long ago? _____________                        Results _____________________________________________________