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35 SW 114 Ave Unit 202 Miami FL 33174 United States
(561) 510-6617
ana@anaorozcomd.com
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Ana Orozco, MD
Miami Functional Medicine Practitioner
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About Ana Orozco
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About
About Ana Orozco
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Ana Orozco, MD
Contact Ana
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Contact Ana Orozco
New Medical History Form
Medical History Form
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Personal Details
Name
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Last
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Female
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Email
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US Address
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Street Address
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West Virginia
Wisconsin
Wyoming
Armed Forces Americas
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Preferred Communication
*
Email
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1. Basic Information
Date of Birth
*
MM slash DD slash YYYY
Height
*
Weight
*
Body Fat Percentage (if known)
Do you wish to Consult: (Check one)
*
A Check Up
For a Particular Concern
For a Particular Concern + Comprehensive Appointment & Health Program
Do you feel that you are basically healthy?
*
Yes
No
What are your primary health concerns?
*
Please share your most frequent health, nutrition, or physique complaints and/or dissatisfactions
*
Please share your most frequent health, nutrition, or physique complaints and/or dissatisfactions
*
If there is any other information you think might be relevant to your program design, please share it with us below.
2. Goals
Please check all that apply to you.
*
Improved health
Fat Loss
Weight Gain
Anti-Aging
Special Event*
Improved Athletic Performance
Increased Muscle Mass
Sport-Specific*
Please provide the special or athletic event for which you are preparing
Do you have a deadline in which you would like to attain these goals?
Yes
No
If so by When?
3. Rest, Recovery & Exercise
What is your stress level at present?
*
Low
Moderate
High
Notes for Stress Levels
What was your stress level in the past 5-10 years?
*
Low
Moderate
High
Notes for Stress Levels
How many hours of sleep do you get a night?
*
Please enter a number from
1
to
16
.
Is it restful sleep?
Yes
No
What time do you go to bed?
*
:
Hours
Minutes
What time do you wake up?
*
:
Hours
Minutes
Do you have Trouble?
*
Falling Asleep
Staying Asleep
Neither
If yes to either, what have you tried to improve your sleep? (medication, natural supplements, meditation, etc.)
Do you have a post work out recovery routine?
*
Yes
No
Details of Post Recovery Routine
During consecutive days of training, do you constantly feel fatigued?
*
Yes
No
If yes, give details
Please list the physical activities that you participate in outside of your professional sport (ie yoga, swimming, etc.)
4. Cravings and Eating Patterms
Do you crave any of the following?
Acidic Foods
Alcohol or Recreational Drugs
Carbohydrates
Chocolate
Coffee or Tea
Fatty Foods
Salt
Soda and Carbonated Drinks
Sweets
Tobacco
Other
Please check all that describe your eating patterns
Eat too much
Emotional Eater
Late night snacking
Poor choices
Eat too little
Fast Eater
Eat out of boredom
Healthy choices
Forget to eat
Hungry all the time
Eat in the car
No joy in eating
Please check all that explain what influences your food choices
Convenience
Family members
Friends
Nutrition
Price
Taste
Approximately what time of the day do you eat the following meals (ie. 8am Breakfast, 12pm Lunch etc):
Breakfast
Lunch
Dinner
What is your history of dieting?
5. Medical History and Present Medical Condition
Personal Medical History. Have you had any of the following conditions? Select For Yes, Leave Blank for No
1. Allergies
2. Loss of hearing
3. Asthma
4. Kidney disease
5. Prostatitis
6. Colitis
7. Hepatitis
8. Liver disease
9. Pancreatitis
10. Elevated liver Enzyme Test
11. Ulcer
12. Heart attack
13. Heart murmur
14. Positive stress test
15. Heart valve abnormality
16. Angina
17. Heart failure
18. High cholesterol
19. High blood pressure
20. Arthritis/rheumatism
21. Loss of consciousness
22. Epilepsy
23. Convulsions / seizures
24. Stroke
25. Diabetes
26. Thyroid trouble
27. Anemia
28. Eczema
29. Sleep apnea
30. Cancer (including skin cancer)
Review of Conditions. EYES, EARS, NOSE, THROAT. Select For Yes, Leave Blank for No
31. Difficulty with night vision
32. Change in your vision
33. Blurred or double vision
34. Bleeding gums
35. Frequent nosebleeds
36. Frequent sinus trouble
37. Recent hoarseness
38. Ringing / buzzing ears
39. Earaches
Review of Conditions. PULMONARY. Select For Yes, Leave Blank for No
40. Shortness of breath
41. A chronic or a frequent cough
42. Brown / blood-tinged sputum
43. Chest tightness
44. Wheezing
Review of Conditions. GENITO-URINARY. Select For Yes, Leave Blank for No
45. Bladder trouble
46. Blood in urine
47. Irregular vagina bleeding
48. Currently pregnant
49. Problems with sexual function
50. Urinating 3 times per night
51. Frequent or painful urination
52. Difficulty starting / stopping urination
Review of Conditions. GASTROINTESTINAL. Select For Yes, Leave Blank for No
53. Vomited blood
54. Persistent diarrhea
55. Persistent constipation
56. Frequent abdominal pain
57. Frequent nausea
58. Frequent indigestion / heartburn
59. Black / bloody bowel movement
60. Hemorrhoids
61. Trouble swallowing
62. Hernia
63. Bloating/Gas
Review of Conditions. CENTRAL NERVOUS SYSTEM. Select For Yes, Leave Blank for No
64. Fainting spells
65. Recurrent dizziness
66. Headaches/migraines
67. Tremors
68. Memory Loss
69. Loss of coordination
70. Difficulty concentrating
71. Numbness / tingling extremities
Review of Conditions. HEART / VASCULAR. Select For Yes, Leave Blank for No
72. Palpitations (irregular heartbeat)
73. Pain or discomfort in chest
74. High cholesterol
75. Swelling of feet
76. Leg pain while walking
77. Painful varicose veins
Review of Conditions. MUSCULOSKELETAL. Select For Yes, Leave Blank for No
78. Back trouble/pain
79. Neck trouble/pain
80. Joint injury/pain/swelling
81. Carpal tunnel syndrome
Review of Conditions. SLEEP . Select For Yes, Leave Blank for No
82. Night sweats
83. Snoring
84. Difficulty falling asleep
85. Waking during sleep
86. Chronic fatigue
Review of Conditions. MISCELLANEOUS . Select For Yes, Leave Blank for No
87. Bleeding / bruising easily
88. Gall Bladder removal or issues
89. Rashes
90. Unexplained lumps
91. Undesired weight loss
92. Low blood sugar
6. General Health, Dietary and Lifestyle
Are you a primary caregiver for children, individuals or an elder relative?
*
Yes
No
If yes, What Role do you play?
Describe your appetite recently
*
Poor - Not very Hungry
Moderate - Typical for you 2-4 Meals a Day
High - Always Hungry and Never Feeling Satisfied
Have you lost or gained weight recently?
*
Yes
No
If yes, how much
Are you currently under a doctor’s care?
*
Yes
No
Being Treated For?
Do you occasionally use or are you currently taking prescription, hormone replacement or over the counter medications?
*
Yes
No
List Prescriptions Hormone Replacements or Over Counter Medications
Have you had any surgical operations in the last 10 years?
*
Yes
No
List Surgical Operations
Has anyone in your immediate family developed heart disease before the age of 60?
Yes
No
Do any diseases run in your family?
Yes
No
List any diseases that run in your family
Do you currently have a cold / cough, or have you had any in the last 2 weeks?
Yes
No
Have you ever been hospitalized?
Yes
No
Do you have a family history of mental illness?
Yes
No
Are you a current cigarette smoker?
Yes
No
How many packs of cigarettes do you smoke in a day? And How long have you been smoking?
Are you an Ex Cigarette Smoker?
Yes
No
How many years did you smoke? How many packs a day? When did you quit?
17. Have you used chewing tobacco or smoked cigars or pipes in the last 15 years?
Yes
No
Alcohol - Do You Drink Alcohol?
*
Yes
No
How many Beers; beers; Ounces of Hard Liquor; Ounces of Wine per Week?
My current Diet could be best Characterized as (check all that apply)
*
Low-fat
Low-carb
High-protein
Vegetarian / Vegan
No special diet
If you have any known food allergies, please list them below:
Are there any foods to which you’re particularly sensitive (i.e., which cause excessive gas, bloating, stuffiness or congestion) please list them below:
Approximately how much money do you spend on groceries per week?
*
Please enter a number from
1
to
500
.
How many times per week do you shop for groceries?
*
Please enter a number from
1
to
20
.
How many meals do you eat in restaurants and / or fast food places per week?
*
Please enter a number from
1
to
20
.
Exactly how much money do you spend on supplements, including protein powder per month?
*
Please enter a number from
1
to
1000
.
7. Nutrition and Supplements - 3 Day Dietary Record
Day One
*
Meal/ Snack
Food Item
Notes
Click on + Symbol to Add Additional Lines (Up to 5)
Day Two
*
Meal/ Snack
Food Item
Notes
Click on + Symbol to Add Additional Lines (Up to 5)
Day Three
*
Meal/ Snack
Food Item
Notes
Click on + Symbol to Add Additional Lines (Up to 5)
Supplement Record
Supplement Name
Dosage
Click on + Symbol to Add Additional Lines (Up to 5)
8. Client Agreement & Release
This Agreement (“Agreement”) is by and between Ana Orozco, MD (“Dr. Ana”) and you the client, (“Client”). Client seeks to engage Dr. Ana as an integrative health coach and nutritionist and Dr. Ana wishes to perform those services for the Client. The Client and Dr. Ana (the “Parties”), in consideration of the mutual promises in this Agreement, agree as follows:
Services and Fees
For the purpose of assisting Client in reaching his/her wellness and/or fitness goals, Dr. Ana shall perform nutritional consulting services (“Services”) tailored to the Client in conjunction with certain recommended supplement products (“Products”). The Services, Products, and potentially various other supplement products provided to Client together comprise the Dr. Ana Personal Client Program (“Program”). As applicable, Dr. Ana will administer a Program that may include Products and various other supplement products, which are not manufactured by Dr. Ana . Dr. Ana will administer a Program in consideration for fees and costs to be billed by invoice and paid by Client per the terms set out on each invoice for Services and/or Products. Client’s failure to timely pay any fees and costs within thirty (30) days of the date of invoice may result in a
late fee charge in the amount of five percent (5%) of the then current outstanding balance, for every thirty (30) days an invoice remains outstanding
.
Indemnification
You, The client holds Dr. Ana harmless and indemnifies it from any and all claims of any nature associated with or arising out of this Agreement, any Services, Products and/or Program, except to the extent any such claims arise from the gross negligence or willful misconduct of Dr. Ana . This Agreement binds the Client, the members of Client’s family and any spouse or domestic partner, if Client is alive, as well as Client’s estate, family, heirs, administrators, personal representatives or assigns, if Client is deceased.
Waiver
Dr. Ana, its employees, nutritionists, and agents do not guarantee (nor is liable for in any degree) any expected results, or lack of results, or undesired consequences, notwithstanding any statements to the contrary by Dr. Ana ’s personnel in the course of any Program, Services or sale of Products. Client acknowledges and fully understands that the use of Dr. Ana Products, Services and participation in any Program may involve certain risks to the Client. Client agrees to allow Dr. Ana to use testimonials and images for use of marketing Services, Programs or Products. Client fully understands and freely agrees to unconditionally, covenant not to sue, waive all rights and remedies, and release any and all claims, losses, damages, or expenses associated with, arising from, or incidental to, in whole or in part, any Services, Program or use of any Products.
Representations
All of the information Client provides to Dr. Ana is true and correct to the best of Client’s knowledge and such information will be relied upon by Dr. Ana in order to provide Services, Products, and any Program, as well as by any athletic and/or fitness training services, recommended as part of any Program. Client understands and agrees that he/she is solely responsible for his/her own compliance with any and all applicable contract obligations, laws, rules, and regulations.
Confidentiality
All information provided by Client to Dr. Ana and by Dr. Ana to Client in connection with the Services or any Program shall be held in strict confidence and neither Party shall disclose any such confidential information without the prior written consent of the other Party, unless: required by court order to do so, or in the event any such information is or becomes public through no breach of this Agreement. Client agrees that Dr. Ana, Dr. Ana and its team may discuss and provide Client’s confidential personal health information, the Services and/or Program concerning Client’s particular case with fellow health practitioners in order to provide the Services.
Severability
If any part of this Agreement is declared unenforceable or invalid, the remainder will continue to be valid and enforceable.
Termination
Either party may terminate this Agreement without cause by giving ten (10) days notice in writing. Upon termination, the Client is obligated to pay Dr. Ana for the Services performed and Products delivered up to the date of termination at the then current rate for such Services and/or Products. If Dr. Ana terminates this Agreement, its only obligation is to reimburse the Client for any credits or pre-payments for Products or Services not yet provided.
Signing
By signing this document, I agree to all of the above information and understand the importance of providing all information to the best of my knowledge.
By signing this document, I agree to all of the above and previous information supplied by me and understand the importance of providing all information to the best of my knowledge.
Your Signature
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Type Your Name
*
Today's Date
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