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? _________________________________
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
Resonance Acupuncture Holistic Health Solutions LLC ! 2
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____
Resonance Acupuncture Holistic Health Solutions LLC ! 3
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: _______________________
Resonance Acupuncture Holistic Health Solutions LLC ! 4
This will be filled in office
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
Resonance Acupuncture Holistic Health Solutions LLC ! 5
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
Resonance Acupuncture Holistic Health Solutions LLC ! 6
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
Resonance Acupuncture Holistic Health Solutions LLC ! 7
For Physician Only:
Patient's Signature: