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. To go back to our main website, please go to WWW.BODYSCIENCE.LIFE
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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]
Hearing Loss [
Perdida de la Audicion]
Glaucoma [
Glaucoma]
Cataracts [
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 [
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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