Medical Form

Send us the form with your information so we can evaluate your case.

The information received will be treated with full confidentiality.

MM slash DD slash YYYY

Reason for consultation

Select the options you want to improve with the use of this therapy

Medical history

Mention that you are allergic and what happens to you
Date or age of diagnosis
Bood pressure is too high (Greater than 130/80mmHg
Arrhythmia, Birth heart problems, heart muscle disease or heart valve disease.
Asthma, Bronchitis, Sleep apnea, COPD (Emphysema), Lung cancer, Lung infection (Pneumonia, Tuberculosis or COVID-19), Pulmonary edema, Pulmonary embolus.
Cirrhosis, Fatty liver, Autoinmmune hepatitis, viral hepatitis
Headaches, Epilepsy, Multiple sclerosis, Parkinson´s, Alzheimer´s, Autism, Huntington´s, Muscular dystrophy, Stroke sequelae.
Mention the antecedent and date it happened
Injuries or trauma, infections, tumors, ankylosing spondylitis, scoliosis, bone changes that occur with age (spinal stenosis and/or herniated discs)
Muscular dystrophy, Neuromuscular diseases, Multiple sclerosis, Fibromyalgia, myasthenia gravis, Myositis, Sarcoma of soft tissue, Bone cancer, Paget´s disease of bone, Bone infections, Osteogenesis imperfecta, Osteonecrosis, Osteoporosis, Rickets.
Systemic lupus erythematosus, Psoriasis, Vitiligo, Addison´s disease, Celiac disease (gluten enteropathy), Dermatomyositis, Grave´s disease, Hashimoto´s thyroiditis, Multiple sclerosis, Myasthenia gravis, Pernicious anemia, Reactive arthritis, Rheumatoid artritis, Sjogren´s syndrome, Ulverative colitis.
Mention the name or type of surgery. Date (Year) or age at the time of surgery and the reason for the surgery
Name the medicines, supplements, and/or vitamins you use and the time you take them

Thank you for answering this questionnaire honestly!