Dr. Suraya Diaz Clinic – Consultation Follow Up Questionnaire

Dr. Suraya Diaz Clinic – Consultation Follow Up Questionnaire 2018-02-21T11:42:16+00:00

Measure Yourself Medical Outcome Profile

Patient's Name:

Please answer the following questions:

What are the main two symptoms you presented in the initial consultation form?

Rate from 1 (as good as it could be) to 6 (as bad as it could be) - IN THE LAST WEEK
Rate from 1 (as good as it could be) to 6 (as bad as it could be) - IN THE LAST WEEK

Name an activity in your live that has been affected by these symptoms?

Rate from 1 (as good as it could be) to 6 (as bad as it could be) - IN THE LAST WEEK

How would you rate your general well-being?

Rate from 1 (as good as it could be) to 6 (as bad as it could be)

Are you taking medication for these problems?

Please write in name of medication, and how much a day / week.

If an important new symptom has appeared, please describe it and mark how bad it is below. Otherwise do not use this line.

Rate from 1 (as good as it could be) to 6 (as bad as it could be)

Go to the next page for 3 more questions...

The treatment you are receiving may not be the only thing affecting your problem. If there is anything else that you think is important, such as changes you have made yourself, or other things happening in your life, please write it here:

Please list the advice that you were not able to follow and possible reasons why:

Did you have any health/life/circumstances changes after your last consultation?

Please make sure you read and understand the Terms of Engadgement & Consent to proceed.