Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com

Thank you for choosing us!!  We look forward to spending the next 45-60 minuetes with you to determine the exact cause and how to fix your health problem.  

Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com
First Name
Last Name
Address
City
Zip Code
Gender
SSN
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length
Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com
Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History
Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:

Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com
Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other
Leone Family Chiropractic
1019 S. 6th St.
Springfield, IL, 6
(217) 525-7100
leonechiro@gmail.com
Please read the following carefully before signing.

I consent to the open nature of the office and understand that every effort will be made to protect private patient information.  That payment is expected at the time of service unless other arrangements have been made.  That should the need arise that all collection costs are my responsibility.  I also understand that this office is focused on finding subluxation (aka pinched nerve) and not as much with the diagnosis of other more in depth diseases. 

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Today's Date: 17 Jul 2018