NEW PATIENT REGISTRATION
PATIENT INFORMATION
Name ___________________________________________________
Last Name
First Name
Date ____________________
Middle Initial
Address _______________________________________________________________________________________________
City ________________________________ State ______________________ Zip Code ______________
Phone Number H ______________________ W _______________________ C ___________________
Email Address _________________________________________________________________________
Sex M F
Marital Status M S D W
Date of Birth ___________________________ Age _____________
Social Security Number ____________________________________
Have you ever received chiropractic care?
Yes No If yes, when? ___________________________
Name of most recent chiropractor ________________________________________________________
Primary Care Physician _________________________________________________________________
Address ______________________________________________________________________________
Phone Number ________________________________________________________________________
EMPLOYMENT INFORMATION
Occupation ____________________________________ Employer ______________________________
Address ______________________________________________________________________________
City ________________________________ State ______________________ Zip Code ______________
Dr. Ryan Wong
4029 West Henrietta Rd Rochester NY 14623
www.chiropros.com
P: 585.321.3200
C: 585.334.8592
PATIENT CONDITION
Symptom ____NECK, MID-BACK, LOW BACK___
Other _____________________________
Please circle one
Visual Analog Scale: Please indicate your level of pain
l ________________________________________________________________________ I
0 (no pain)
(worst possible pain) 10
Type of Pain (circle all that apply)








Dull/Achy
Sharp
Burning
Tingling




Numbness
Swelling
Throbbing
Stabbing
Cramping
Shooting
Stiffness
Other
Frequency of Pain


Constant (76-100% of the time)
Frequent (51-75% of the time)


Occasional (26-70% of the time)
Intermittent (0-25% of the time)



Lifting
Driving
Walking
What Makes the Symptoms Worse? (circle all that apply)


Sitting
Standing

Getting up
from sitting
position


Running
Other
_________
What Makes the Symptoms Better? (circle all that apply)




Rest
Ice
Heat
Stretching



Exercise
Massage
Prescribed Pain
Medications
Does the symptoms radiate to another part of the body?


OTC Medications
Nothing
Yes No Where? ____________________
Is the symptom worse at certain times of the day or night? (Circle One)


Morning
Afternoon


Evening
Night
What other treatments have you had for this condition?
 Physical Therapy
 Surgery
Dr. Ryan Wong
4029 West Henrietta Rd Rochester NY 14623
www.chiropros.com

Unaffected by time
of day

Chiropractic
P: 585.321.3200
C: 585.334.8592
PAST MEDICAL HISTORY
Exercise


Moderate

Daily

Heavy
Sitting

Standing

Light Labor

Heavy Labor
None

Mild

Moderate

Severe

Alcohol

Drugs

Caffeine
None
Work Activity

Stress

Lifestyle

Smoking
Dr. Ryan Wong
4029 West Henrietta Rd Rochester NY 14623
www.chiropros.com
P: 585.321.3200
C: 585.334.8592
PAST SURGICAL PROCEDURES (please describe and include date)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
MEDICATIONS
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
VITAMINS/SUPPLEMENTS
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ALLERGIES
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
FAMILY HISTORY
Does anyone in your immediate family have/had any of the following conditions? (if yes, specify who)
______________________________________________
Patient Signature
Dr. Ryan Wong
4029 West Henrietta Rd Rochester NY 14623
www.chiropros.com
___________________
Date
P: 585.321.3200
C: 585.334.8592
Office Financial Policy
Our financial policy has been set up to prevent misunderstandings. We like to acknowledge patients who take a responsible
approach to paying for their medical care.
1.
2.
3.
4.
5.
6.
Full payment is expected at the time of service unless other arrangements are made in advance.
A service charge of 2.0% per month on the unpaid balance will be charged after 30 days. After 90 days if prior
arrangements for a payment plan are not made and no payments having been made your account will be referred to
a collection agency.
If an appointment is broken or cancelled without 24 hours notice a service charge of $45.00 will be applied to your
account.
Returned checks are subject to a $35.00 service charge and will terminate our privilege to pay by check on future
visits.
It is understood and agreed that in the event any outstanding balance has to be referred to a collection agency or
attorney for recovery, you will be responsible for all collection agency fees and attorney’s fees.
I agree to take full financial responsibility for my chiropractic care in the event that the assumed insurance coverage is
denied.
Informed Consent
While chiropractic care has been shown to be extremely beneficial for most people, everyone responds to treatment
differently. If you are not responding well to care, other treatment options are available. Your chiropractor may suggest these
other options which may include: self administered over the counter analgesics and rest, medical care and prescription drugs,
hospitalization, surgery, physical therapy, massage therapy, or acupuncture. Remaining untreated may allow the formation of
adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time, this process may
complicate treatment making it more difficult and less effective the longer it is postponed. Chiropractic care, like all forms of
care, has potential inherent risks associated with its application. Your chiropractor is well trained will do everything in his power
to minimize the possibility of these occurrences through a proper and thorough examination as our patient’s health and wellbeing is our primary concern. Some of the risks which we wish to make patients aware of are post-treatment soreness, physical
therapy burns, fractures, sprain/strains and strokes. If you have any questions or concerns regarding any of the above potential
risks, please do not hesitate to address them with your doctor.
Health Insurance Portability and Accountability Act of 1996 (HIPAA), Privacy Practices
The above act ensures a patient’s right to privacy regarding Personal Health Information and it is our office policy to maintain
confidentiality to the highest degree with all patient information. A complete copy of the HIPAA is available from the reception
desk upon your request. Please feel free to ask your doctor or office personnel regarding any questions or concerns.
For Rush-Henrietta Family Chiropractic to disclose private health information about your to parties not covered in our Notice of
Privacy Practices, you will need to complete this section.
____ Yes, you may provide information to the parties listed below:
________________________________________
________________________________________
________________________________________
____ No, I do not wish Rush-Henrietta Family Chiropractic to discuss my information with any party other than myself.
______________________________________________
Patient Signature
Dr. Ryan Wong
4029 West Henrietta Rd Rochester NY 14623
www.chiropros.com
___________________
Date
P: 585.321.3200
C: 585.334.8592