Neurodegenerative Program Registration Form

Neurodegenerative Program Registration Form

Thank you for completing the intake form. Please take your time and be as detailed as you can be, we use this information for the Health Discovery Session, to better assess next steps and treatment plans moving forward. Also, to make the meeting more efficient and avoid having to ask the same questions that didn't get answered. If you have any questions, please call us at 305-901-5888 or email us at info@bodyscience.life
Name (Nombre)*

First Name (Nombres)Last Name (Apellidos)
Date of Birth (Fecha de nacimiento)*

MonthDayYear
Age (Edad)
Gender (Genero)

Male (Masculino)Female (Femenino)MTFFTM
Today's Date (El día de hoy)

MonthDayYear
Date
Email (Correo Electronico)*
example@example.com
Address (Dirección)

Street Address

Street Address Line 2

City (Ciudad)State / Province (Estado/Provincia)

Postal / Zip Code (Código Postal)Country
Phone Number (Número de Teléfono)

Area Code (Código de Area)Phone Number (Número de Teléfono)
Occupation (Ocupación)
Primary Doctor (Doctor primario)

First NameLast Name
Primary Doctor Phone Number (Número de teléfono de doctor primario)

Area CodePhone Number
How Did You Hear About Us? (¿Como supiste de nosotros?)

Goals for initial meeting (Objetivos para la consulta)*
This field is required.
Top 3 Questions/ Priority for Amy and Medical Team (3 Preguntas Mas Importantes)*
This field is required.
Please provide us a thorough timeline of your diagnosis, this includes the month, season, and/or year of first symptoms (e.g.: Dec 2001 - Diagnosed with High Blood Pressure, Feb 2002 - Weakness in Right Arm began) [Proporcione un breve cronograma de la historia médica y/o la progresión de la ELA (por ejemplo: diciembre de 2001: diagnosticado con presión arterial alta, febrero de 2002: comenzó la debilidad en el brazo derecho)]*
This field is required.
Please list the names of people who will be joining the zoom and their relationship to the patient. (Please note, we only allow 2 guest to join zoom call, if additional people would like to attend, please reach out to our office) [Nombrar las personas que estarán en la videoconferencia y su relación al paciente (por favor limitar los invitados a 2)]
List of Current Medications [Lista de Medicamentos]*
This field is required.

How is your Speech? [Describe si tienes problemas para hablar]
How is your Salivation? [Describe si tienes problemas de salivación]
How is your Swallowing [Describe si tienes problemas de deglución]
How is your Handwriting [Describe si tienes problemas para escribir]
Describe your ability to cut food and handle utensils [Describa su capacidad para cortar alimentos y utilizar utensilios.]
Describe your ability to dress yourself and perform hygiene-related tasks [Describa su capacidad para vestirse y realizar tareas relacionadas con la higiene.]
Describe your ability towards turning in bed [Describa su habilidad para girar en la cama.]
Describe your walking [Describe tu habilidad de caminar]
Describe Your Climbing Stairs [Describa tu habilidad de subir escaleras]
Describe Your Breathing [Describe tu respiración]
Do you have Bulbar symptoms? [¿Tienes síntomas de Bulbar?]

YesNo
Please list all treatments and/or medications that you have tried or are currently taking: [Enumere todos los tratamientos y / o medicamentos que han tomado o está tomando actualmente:]
Please list all supplements and dosing that you are currently taking: [Enumere todos los suplementos y las dosis que está tomando actualmente:]
Please upload all relevant medical records. [suba todos los registros médicos relevantes.]

Browse Files
You can also send all records to [Además podes enviar tus registros medicos a] info@bodyscience.life Cancelof
Any Additional Comments & Thoughts [Cualquier comentario adicional y pensamientos]
Having read all the information above as well as providing all the appropriate personal information, I agree to the terms and hereby state that all my information given is correct. [Después de leer toda la información anterior y completar toda la información personal apropiada, acepto los términos y por la presente declaro que toda la información que proporcioné es correcta.]

Clear
Should be Empty:

	Mother (Madre)	Father (Padre)	Other (Otro)
Cancer
Diabetes
Heart Disease (Enfermedad del corazón)
Hypertension (Hipertensión)
Psychiatric Disorder (Desorden psiquiátrico)
Stroke (Derrame Cerebral)
Obesity (Obesidad)
Osteoporosis

	Yes [Si]	No
Shortness of Breath (at rest) [Falta de aliento (en reposo)]
Night sweats [Sudores nocturnos]
Productive cough [Tos productiva]
Bloody cough [Tos sanguinolenta]
Tuberculosis
Pneumonia [Neumonía]
Emphysema [Enfisema]
Asthma [Asma]
Sleep Apnea [Apnea del sueño]

	Yes	No
Chest pain [Dolor de pecho]
Hypertension [Hipertensión]
Heart Attack [Ataque al corazón]
Heart Failure [Insuficiencia cardíaca]
Heart Murmur [Soplo cardíaco]
Mitral Valve Prolapse [Prolapso de la válvula mitral]
Palpitations (racing heart beat) [Palpitaciones (latidos cardíacos acelerados)]
Peripheral vascular disease [Enfermedad vascular periférica]
Edema (swelling of hands/feet) [Edema (hinchazón de manos / pies)]

	Yes	No
Abdominal Pain [Dolor abdominal]
Heartburn [Acidez]
Ulcer [Úlcera]
Acid Reflux [Reflujo ácido]
Vomiting/Nausea [Vómitos / náuseas]
Excessive Pain [Dolor excesivo]
Rectal Bleeding [Sangrado rectal]
Colitis
Gallstones [Cálculos biliares]
Constipation [constipación]
Diarrhea [Diarrea]

	Yes	No
Depression [Depresión]
Bipolar depressive illness [Enfermedad depresiva bipolar]
Schizophrenia [Esquizofrenia]
Anxiety/Panic Disorder [Ansiedad / trastorno de pánico]
Panic Attacks [Ataques de pánico]

	Yes	No
Headaches [Dolores de cabeza]
Dizziness [Mareo]
Numbness [Entumecimiento]
Epilepsy [Epilepsia]
Seizure disorder [Trastorno convulsivo]
Fainting [Desmayo]

	Yes	No
Enlarged prostate [Hipertrofia prostática]
Frequent night time urination [Micción nocturna frecuente]
Blood in urine [Sangre en la orina]
Burning upon urination [Ardor al orinar]

	Yes	No
Seasonal Allergies [Alergias estacionales]
Hearing Loss [perdida de la audición]
Glaucoma [Glaucoma]
Cataract [Cataratas]

	Yes	No
High Thyroid (hyper) [Tiroides alta (hiper)]
Low Thyroid (hypo) [Tiroides baja (hipo)]
Diabetes
Low Blood Sugar [Baja azúcar en la sangre]
Gout [la Gota]

	Yes	No
Aching muscles/joints [Dolor muscular / articulaciones]
Low back pain [Dolor lumbar]
Muscle Cramps [Calambres musculares]
Osteoporosis
Arthritis [Artritis]

	Yes	No
Cancer
Anemia
Fatigue [Fatiga]
Hot/Cold Spells [Hechizos fríos / calientes]
High cholesterol [Colesterol alto]