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 A Winter Park - FL 32789 407 636 4437 Do you believe you are or may be pregnant ? NO YES how long? _________________________________
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Date ________________ Gender F M Last 4 digits of your SS#___________________
First Name ___________________________Last Name____________________Middle______________________
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: _______________________________________________________________________________________________
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
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: _______________________
Resonance Acupuncture Holistic Health Solutions LLC ! 4
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:
! 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
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
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? ________________________________