BodyScience Medical Registration Form
Please complete our HIPAA Compliant Registration form before scheduling an appointment. BodyScience is the bridge between pure science and the practice of medicine
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Age (Edad)
Name (Nombre)
*
First Name
Last Name
Address (Dirección)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (Correo electrónico)
*
example@example.com
Phone Number (número de teléfono)
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Area Code
Phone Number
I am Interested on the Following Program(s)
Bio-Identical Hormone Replacement
MTHFR Mutation
Fertility
Menopause
Mood Disorders
Migraine Relief
PCOS
Leaky Gut Syndrome
ADD/ADHD
Genetic Testing
Adrenal Health for Men
Low Testosterone
Parent or Guardian Signature (if patient is a minor): [Firma del familiar o tutor (si el paciente no tiene facultad de firmar):]
Clear
Occupation (Ocupación)
Primary Doctor (Doctor primario)
First Name
Last Name
Primary Doctor Phone Number (Número de teléfono de doctor primario)
-
Area Code
Phone Number
How Did You Hear About Us? (¿Como supiste de nosotros?)
Back/Atras
Next
Please select all of the following that you have been tested for: [Seleccione todo lo siguiente para lo que se le realizó la prueba:]
Mold
Heavy metals [Metales pesados]
Nutritional Testing [Pruebas nutricionales]
Genetic Testing [Prueba genética]
Family History (historial médico familiar)
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
Habits (please select all that apply) [Hábitos (seleccione todos los que correspondan)]
Smoke?
Alcohol?
Do you have any allergies to foods or medications? (if so, please list all) [¿Tienes alguna alergia de alimentos o medicamentos? (en caso afirmativo, enumere todos)]
Please list all hospitalizations (if any) [Enumere todas las hospitalizaciones (si hay)]
Please list all surgeries (if any) [Enumere todas las cirugías (si hay)]
Chronic illnesses [Enfermedades crónicas]
Do you have an alcoholism or drug problem? (if so, please describe) [¿Tienes un problema de alcoholismo o drogas? (si es así, por favor describa)]
Respiratory System - Please select all that apply to you - if unsure, select the truer choice. [Sistema respiratorio: seleccione todo lo que le corresponda; si no está seguro, seleccione la opción más verdadera.]
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]
Cardiovascular
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)]
Gastrointestinal
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]
Psychological [Psicológico]
Yes
No
Depression [
Depresión]
Bipolar depressive illness [
Enfermedad depresiva bipolar]
Schizophrenia [
Esquizofrenia]
Anxiety/Panic Disorder [
Ansiedad / trastorno de pánico]
Panic Attacks [
Ataques de pánico]
Neurological [Neurológico]
Yes
No
Headaches [
Dolores de cabeza]
Dizziness [
Mareo]
Numbness [
Entumecimiento]
Epilepsy [
Epilepsia]
Seizure disorder [
Trastorno convulsivo]
Fainting [
Desmayo]
Genitourinary [Genitourinario]
Yes
No
Enlarged prostate [
Hipertrofia prostatica]
Frequent night time urination [
Micción nocturna frecuente]
Blood in urine [
Sangre en la orina]
Burning upon urination [
Ardor al orinar]
Ears, Eyes, Nose & Throat [Orejas, ojos, nariz y garganta]
Yes
No
Seasonal Allergies [
Alergias estacionales]
Cleanliness [
perdida de la audicion
Responsiveness [
Glaucoma]
Friendliness [
Cataratas]
Endocrine [Endocrina]
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]
Bones, Joints, Muscles [Huesos, articulaciones, músculos]
Yes
No
Aching muscles/joints [
Dolor muscular / articulaciones]
Low back pain [
Dolor lumbar]
Muscle Cramps [
Calambres musculares]
Osteoporosis
Arthritis [
Artritis]
Other [Otro]
Yes
No
Cancer
Anemia
Fatigue [
Fatiga]
Hot/Cold Spells [
Hechizos fríos / calientes]
High cholesterol [
Colesterol alto]
Back
Next
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. [Cargue todos los registros médicos relevantes.]
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You can also send all records to [Ademas podes enviar tus registros medicos a] info@bodyscience.life
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Any Additional Comments & Thoughts [Cualquier comentario adicional y pensamientos]
Having read all the information above as well as filled out 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.]
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Submit/Enviar
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