New Patient’s Information

Date ________________ Gender F M Last 4 digits of your SS#___________________

First Name ___________________________Last Name____________________Middle______________________

Address ____________________________________City________________ State______ Zip________

Date Of Birth____________ Country/ State ____________

Marital Status: ! Single ! Married ! Divorced ! Separated ! Widowed ! Partner Children?___ age:_____

Occupation______________________________ ! Full Time ! Part time How Many Hours/week? ___

Name of your Medical Doctor: _______________________________________________

Other Healthcare providers: _______________________________________________

How did you hear about us or who referred us ?__________________________________________________________________________________________

Did you have acupuncture before, if so for what reason?_____________________________________________________________________________________

Hobbies ___________________________________________________________________________

______________________________________________________________________________________________

Email _______________________________________________________

Home Phone______________________ Mobile________________________ Work: __________________________

Please list family members or other persons, if any, whom we may contact in case of MEDICAL EMERGENCY ONLY.

Name_____________________________ Phone_________________________ Relationship: ______________________

Name_____________________________ Phone_________________________ Relationship: ______________________

AUTHORIZATION NOTICE

Do you allow us to send you emails to the above indicated email address for all our future correspondence including appointment reminders, invoices, medical documents, News letters, marketing & events we would organize? Yes -No

Do you authorize us to leave any detailed voice message on your Home phone? Yes -No On indicated Mobile? Yes -No

Contact me for appointment confirmation via: Text MSG: Yes No Phone call: Yes No

Resonance Acupuncture Holistic Health Solutions LLC ! 1

New Patient’s Information

665 Harold Av, Suite AWinter Park - FL 32789407 636 4437

Do you believe you are or may be pregnant ? NO YES how long? _________________________________

The Salt Roomand Wellness SPA508 N Mills Av - Orlando Fl 32803

Do you have or had have any of the following conditions ? If yes, please indicate date of diagnosis: Date Date

Indicate close family members (Gran Mother, mother,father, etc) with any of the following:

Others_____________________________________________________________________________________ Do you exercise? How often? What exercise routine? How many Minutes/ hours a Day/ week? Describe: _______________________________________________________________________________________________

_______________________________________________________________________________________________

What are you ALLERGIC to? _______________________________________ _____________________________________

_______________________________________ ______________________________________

Pacemaker

Seizure disorder

Metal in body

Hypoglycemia

Diabetes

Stroke

High Blood Pressure

Mental illness/

_________________________________________________________________________________________________

Bleeding disorder

Anemia

Cancer type ___________

HIV

Hepatis ( A, B, C, D)

Thyroid Disorder : Hypo / Hyper

Heart Disease

Other ___________________

________________________________________________________________________________

Allergies Heart Disease Diabetes

Asthma Stroke Cancer

Blood Pressure High Cholesterol/ Mental illness

Please list any past accidents, severe falls, major injuries, fractures, dislocation, cuts, etc.

Date Type

Indicate where you have SCARS


List all supplements, vitamins, herbs & medications you are currently taking:

Have you been exposed or currently exposed to chemicals, or other toxic environment? work? home? describe __________________________________________________________________________________________________________________________________________________________________________________________________

Please describe your average daily diet

Do you consume ? indicate how much :

- Cigarettes? ____ How many a day?_____ How long?_____

- Alcohol? _____ What type?_____ How glass/ Bottle a day? _____

- Coffee? _____ How many cups a day? _____

- Soda? _____ What Type? _____ How Many glass/ Can a day? _____

- Tea ? _____ Black? Green? Red? Herbal? How many cups a day?_____

Dosage Name indication

Breakfast time:___

Lunchtime:____

Snackstime ____

Diner time____


I

List major complaints in order of significance to you, and If there is Pain please rate your pain from 1 to 10, 10 being Highest level of pain.

Issue When it stated Pain from 1 to 10

1

2

3

Point with the following letters WHERE you have discomfort and the corresponding description: “X” Sharp/Stabbing “N” Numbness “P” Pins & Needles “T” Tightness/Spasm “D” Dull/Aching

What makes the pain BETTER? What makes the pain WORSE?

! soft pressure ! hard pressure ! Cold

! Heat ! Exercice / movement ! Rest, after a night sleep other: _______________________

! soft pressure ! hard pressure ! Cold

! Heat ! Exercice / movement ! Rest, after a night sleep other: _______________________


This will be filled in office

RAD PDF

How does these conditions impair or limit your daily activities? ______________________________________________________________________________________

How much water you drink per day indicate Oz/cups / glass _________________________________________

How many hours per night do you sleep on average? _______ Do you wake rested?_______

How is your energy Level? Please circle. Low < 1 2 3 4 5 6 7 8 9 10 > High

What time of day is your energy

Do you fatigue easily? !Yes ! No

How do you feel emotionally? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

How do you describe yourself with your own words ? Example: Hyperactive, slow, enjoyable, grumpy, funny, easy going, solitary, timide, competitive, etc _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

How are your stress levels? Please circle. Low < 1 2 3 4 5 6 7 8 9 10 > High

Please select what you have experienced in the last 3 to 6 month:

Highest !6am-12pm !1pm-5pm !6pm-12am Lowest !6am-12pm !1pm-5pm !6pm-12am

Emotions / sleep

! Insomnia ! Nightmares ! Difficulty Falling Asleep ! Difficulty Staying Asleep ! Waking up several time a night what time? _____________________ ! Waking Up Early what time? ________ ! Restless Sleep

! Poor memory ! short memory loss ! long term memory loss ! Difficulty concentration ! Panic attacks ! get angry / Annoyed easily ! Nervousness ! Suppressed Emotions ! Frequent Sighing ! Easily Startled

! Irritable ! Difficulty making decisions ! Mood Swings ! Anxiety / worries ! Depression ! Stress ? ! Home ! Work ! Relationship ! General ! Excessive Dreaming How you wake up? ! rested ! Tired

Skin

! Rashes/Eczema/Hives/Psoriasis ! Dry Hair ! Hair Loss ! Changes in Skin Color

! Easy Bruising ! Acne ! Dry / Itchy Skin ! Brittle Nails

Head, Eye, Ear, Nose, and Throat

! Eye Dryness ! Eye Floaters or Spots ! Blurry Vision ! Poor Night Vision ! Ringing in Ears ! High pitch ! Low Pitch

! Hearing Difficulties ! Headaches / Migraines ! Teeth Grinding / TMJ ! Sore Throat ! Chronic Sinus Congestion

! Dry Mouth ! Bad Breath ! Mouth Sores / Ulcers ! Bleeding Gums ! Increase in Thirst


Energy and Immunity

! Fatigue ! Allergies (which?)___________ ! Anemia

! Chronic Fatigue Syndrome ! Thyroid Problems ! Tendency to Catch Colds ! Sudden Weight Change

Male Health

! Prostate Enlargement ! Impotence ! Painful testes ! Groin Pain

! Premature Ejaculation ! Decreased Libido ! Cannot maintain erection

Did you ever had a Prostate check? Y / N ? Date? ________ Diagnosis?____________________ Past or present genital infection and/or Urinary tract infection? _______________________________________________________________________________________________________________________________________________________________

Gastrointestinal disorders -

! Changes in Appetite ! Nausea / Vomiting ! Bloating ! Pain: ! right after meal ! 1or 2h after meal

! Gas ! Heartburn / Acid Reflux ! Belching / burping ! loud ! soft ! a lot ! little ! normal ! feeling of Distented Belly

! Hemorrhoids ! Diarrhea ! Constipation ! Ulcers (GIT) When?___________ ! Hiatus Hernia- When ?________

Neurological disorder

! Vertigo / Dizziness ! Numbness / Tingling ! Poor Concentration or Memory

Other diagnosed:

_________________________________________________________

Kidney/Urinary Color of urine? ! Pale ! Yellow ! Dark Yellow ! Other:

! Painful Urination ! Frequent Urinary Tract Infections ! Urgent Urination ! Frequent Urination, more so ! during day ! Night ! all day Since when? ________________________________

! Edema / Swelling ! Incontinence ! Permanent ! on effort

! Since when? ____________________ ! kidney Stone History last in date? _____________________

Respiratory/Cardiovascular/ Vascular

! Shortness of Breath ! Only on movement/ exercising ! Asthma ! Chest Pain ! Heart Palpitations / Fluttering

! Chronic Cough ! Night Sweats ! Particularly sensitive to the cold ! Particularly sensitive to heat

! Poor Circulation (Cold hands/feet)! Varicose veins ! Spider veins ! Unusual Sweating

Bowel movements -

How often?______time(s) a day, or _____ time(s) a week I have or had: ! Irregular Bowel Movements ! Constipation

! Burning sensation of the anus ! Hemorrhoids ! Itchiness ! Loose stools ! Hard stools

! Diarrhea ! Painful bowel movements ! Undigested food in stools ! Blood in stools ! Gas


FOR WOMEN ONLY

Are you in Menopause ? Y / N Since when / age ? __________ In Pre Menopausal? Y/ N When it started?____________

Age of your first Menses?_____

Do you have a cycle ? Y / N Is your cycle: ! Regular ! Irregular

Do you use any type of contraceptive methods ? Y / N

If Yes: ! Contraceptive Pill, brand __________________ Since when / how many years:_______________________

! Tube Tied Date:______________ ! Other: _____________________________

Date of last ONGYN check? ______________________ PapSmear____________ Diagnosis:___________________

fecha de ultimo chequeo Ginecologico? _____________ Papanicolaou:_________ Diagnosis ___________________

Do you experience Menstrual Pain ! Before ! During ! After ? Do you experience Headache / migrain ! Before ! During ! After your menstruation?

If IRREGULAR Cycle, please describe your cycle details

Date of last cycle: They last how many days?

If REGULAR, please describe

Date of last cycle:___________ “They” come every _____days How many days is your flow ? ______

Choose one Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

COLOR: Pale, Bright red, Brown rust, Dark purple, Pink, orange, other

FLOW: Normal, Heavy, Light

PAIN, cramps: Dull, Sharp, other

V= Vomiting N = Nausea

H= Headaches - M= Migrain

Describes the Clots : a lot, big, string like, few, very thin

! Mid-cycle mucus ! Vaginal discharge. Colour?______ ! Unusual Vaginal Discharge Odor ! Hot flashes ! Vaginal Dryness ! Breast Lumps / Cysts

! Uterine Fibroids ! Endometriosis ! Frequent Yeast Infections ! Decreased Libido ! Irritability ! Breast Tenderness

! Cravings ! Cramps ! Menstrual Related Moodiness ! “ “ Breast-Tenderness ! Menstrual Related Bloating ! Bleeding Between Cycles ! Ovarian Cysts


For Physician Only:

Patient's Signature:

RAD PDF

Documents

New Patient’s Information