Spine & Sports Therapy - New Patient History
Date of Birth*
Please select your doctor.*
Dr. Jeffrey C. Fiero, D.C., CCSP
Dr. Daniel W. DeWalch, D.C., CCSP, FIAMA
Dr. Matthew Brackney, D.C., ATC
Dr. Daniel DeWalch, D.C., CCSP, FIAMA
Dr. Jeffrey Fiero, D.C., CCSP
Dr. Matthew Brackney, D.C., CCSP® -Kingwood Location
Jordan Whitehead, CSCS, FMS, Pn1
Dr. Matthew Brackney, DC, Certified Chiropractic Sports Practitioner® 10 Minute Consultation Call (Free)
Emergency Contact - Name & Phone
Emergency Contact Relation to patient
Please describe your symptoms (dull/achy, sharp/shooting, numbness/tingling/burning)
Have you ever received Chiropractic Care?
If you have received Chiropractic Care, when was your last treatment?
Do you have any concerns about Chiropractic Care?
Please list any previous injuries (muscle strains, dislocations, ankle sprains, automobile accidents, slips/falls, etc...):
Have you ever broken any bones? Please list any previous surgeries.
Do you have Osteopenia, Osteoporosis or any other bone condition?
Family Health History. Do you have any relatives who have the same condition?
Social History (smoker or non-smoker, alcohol consumption, etc...)
Rescheduling, Missed Appointment & Cancellation Policy
Patient's Initials (Rescheduling, Missed Appointment & Cancellation Policy above)*
Patient's Initials (HIPAA Notice)*
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE SELECT THE APPROPRIATE DROPDOWN AND INITIAL BELOW.
Informed consent read options*
I have read
I have had the above read to me
Patient's Initials (Informed Consent)*
Financial Responsibility, Authorization & Release
Credit Card Number*
CSV (three or four digit code on the back or front of the credit card)*
Patient's Initials (Financial Responsibility, Authorization & Release)*
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND ALL THE ABOVE.
CONSENT TO TREATMENT (MINOR)
Name of Minor (please use N/A if you are not a minor)*
Signature of Parent/Guardian (please use N/A if you are not a minor)*