New Patient Health History Form

In order to provide you the best possible wellness care, please complete this form

Patient Data

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Nature of Injury
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Have you ever had same condition?
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Have you ever been under chiropractic care?
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Have you been treated for any conditions in the last year?
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Is there a chance that you are pregnant?
Have you had X-rays taken?
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Broken bones?
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Been hospitalized?
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Had surgery?
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Do you experience pain every day?
Do your symptoms interfere with daily life?
Does pain wake you up at night?
Are your symptoms worse during certain times of the day?
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Alcohol
Coffee
Tobacco
Exercise
Sleep
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Please do not submit any Protected Health Information (PHI).

Location

--mi
Address

2819 Bragg Blvd.
Fayetteville, NC 28303

Contact Information (910) 484-2001

HOURS OF OPERATION

Monday  

8:30 am - 12:00 pm

2:00 pm - 5:30 pm

Tuesday  

8:30 am - 12:00 pm

2:00 pm - 5:30 pm

Wednesday  

8:30 am - 12:00 pm

2:00 pm - 5:30 pm

Thursday  

8:30 am - 12:00 pm

2:00 pm - 5:30 pm

Friday  

Closed

Saturday  

Closed

Sunday  

Closed