BodyScience Medical Intake Form

BodyScience Medical 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*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Gender

MaleFemaleMTFFTM
I'm sicking help for:*

ALS (Neurodegenerative)Functional Medicine
Today's Date

MonthDayYear
Date
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code Country
Phone Number

Area CodePhone Number
Occupation
Primary Doctor

First NameLast Name
Primary Doctor Phone Number

Area CodePhone Number
How Did You Hear About Us?

Goals for initial meeting*
This field is required.
Top 3 Questions/ Priority for Amy and Medical Team*
This field is required.
Please provide us a thorough timeline of your diagnosis, this includes the month, season, and/or year of first symptoms*
This field is required.
List of Current Medications*
This field is required.

Please upload all relevant medical records.

Browse Files
You can also send all records to [Además podes enviar tus registros medicos a] info@bodyscience.life Cancelof
Below for Neurodegenerative Diseases Only (ALS, Parkinson's, Alzheimer's, MS)

For functional patients, no need to complete this part
Neurodegenerative Program you are seeking help with:

ALS - Amyotrophic Lateral SclerosisParkinson's DiseaseAlzheimer's diseaseMS - Multiple Sclerosis
How is your Speech?
How is your Salivation?
How is your Swallowing
How is your Handwriting
Describe your ability to cut food and handle utensils
Describe your ability to dress yourself and perform hygiene-related tasks
Describe your ability towards turning in bed
Describe your walking
Describe Your Climbing Stairs
Describe Your Breathing
Do you have Bulbar symptoms?

YesNo
Please list all treatments and/or medications that you have tried or are currently taking:
Please list all supplements and dosing that you are currently taking:
Any Additional Comments & Thoughts
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.
Should be Empty:

Rows	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

Rows	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]

Rows	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)]

Rows	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]

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

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

Rows	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]

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

Rows	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]

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

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

Below for Neurodegenerative Diseases Only (ALS, Parkinson's, Alzheimer's, MS)