New Patient Forms

New Patient Forms & Questionnaires

Dear Prospective New Patient,

Thank you for coming to our website to prepare for your initial office visit. Please find below, several categories of patients, and their unique forms to complete prior to seeing the doctor.

We ask that ALL new patients complete the initial "Health History Questionnaire".

Then, browse through the other categories, and complete and sign the appropriate forms.

If you have any questions, please call us at 806-796-0098.

Intake Forms

All New Patients:

Health History Questionnaire

If you have Regular Medical Insurance:

Insurance Authorization of Benefits

If you have Medicare:

Notice To Medicare Patients

Acupuncture Patients:

Acupuncture Disclosure and Consent

Chiropractic Patients:

Spinal Manipulation Disclosure and Consent

Symptoms Forms

If you are having any symptoms, please fill out the first form, the Quadruple Visual Analog Scale (QVAS).

Then choose from the selected body parts below and complete the appropriate form(s).

All New Patients:

Quadruple Visual Analog Scale (QVAS)

Then choose the most appropriate for you:

Headache Disability Questionnaire

Dizziness

Tinnitus

Temporomandibular Joint (T.M.J)

Neck Pain

Shoulder Pain & Disability

Elbow Pain

Wrist Form

Carpal Tunnel Syndrome

Back Pain (Revised Oswestry)

Hip Rating Form

Knee Score Form

Patellofemoral Form

Ankle Grading System Form (some to be completed by physician)

Broussard Clinic of Chiropractic & Acupuncture

A Conservative Approach To Health Care