Dr. Suraya Diaz Clinic – Initial Questionnaire

Dr. Suraya Diaz Clinic – Initial Questionnaire 2018-10-17T16:03:47+00:00

Initial Consultation Questionnaire

Section 1

Personal Details
Form Submission Date
Name
Address
Date of Birth
Occupation
Telephone
Mobile number
Email
Referred by

Your Health

Your Height
please, specify your height in centimeters
-
+
Your Weight
Please, specify your weight in kilograms
-
+
Number of Children
-
+
Your Blood Type
Martial Status
Do we have permission to contact your GP?
GP's Name
GP's Address
GP's Phone
Are you currently seeing any other practitioners?
Please, describe briefly the work you have been doing with them.

Section 2

Presenting Compliant/-s

What are the two main concerns that bring you to this clinic?

Symptom 1
Please rate from 1 (as good as it could be) to 6 (as bad as it could be) how severe your problems have been IN THE LAST WEEK
Symptom 2
Please rate from 1 (as good as it could be) to 6 (as bad as it could be) how severe your problems have been IN THE LAST WEEK

What activity in your life has been affected by these symptoms?

Activity
Please rate from 1 (as good as it could be) to 6 (as bad as it could be) how much has the mentioned activity been affected

How would you rate your general wellbeing?

Please rate from 1 (as good as it could be) to 6 (as bad as it could be)
Are you currently taking any prescribed or self-administered medication?

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

Please list any medication you are currently taking (e.g. oral contraceptive pill, antibiotics, steroids, etc), supplements or herbs...

Section 3

Previous Medical History

Please indicate your childhood diseases from the list below:

Did you have any major/ recurrent illnesses during your life?

Please indicate if you have any:

Regarding your health family history, what are the major health problems in your family, including major health details of grandparents, parents and siblings:

Section 4

Lifestyle and Body Systems

Regarding your lifestyle please indicate if you consume:

How many hours do you work per week on average?

Please rate your job satisfaction:

(1 as good as it could be), 6 (as bad as it could be)

Please indicate the affirmations that apply to you:

How would you rate your general Immunity / infections, wellbeing and energy?

Immunity
Wellbeing
Energy
Do you generally feel cold or warm?

Concerning your Cardiovascular System please indicate if you experience any of the described below:

Concerning your Respiratory System please indicate if you experience any of the described below:

Concerning your Digestive System please indicate if you experience any of the described below:

How regularly do you have bowel movements?

Continue on the next page...

Section 4 - Continuation

Lifestyle and Body Systems

What is the color of your stool? Please indicate any correct option

Please indicate shape & size of stool type in the chart

Regarding your Urinary System, please indicate the color of your urine in the middle of the day.

Please indicate any correct options regarding your Urinary System

Regarding your Reproductive system please indicate please if you experience any of the following

Regarding FEMALE Reproductive system, please indicate the length of your menstrual cycle:

Regarding a FEMALE Reproductive system, please indicate any correct option:

Regarding FEMALE Reproductive system, please indicate the color(s) of your blood during your period:

Concerning your Nervous System please indicate any option that would apply to you:

Continue on the next page...

Section 4 - Continuation

Lifestyle and Body Systems

Please indicate the options that most apply to your sleep patterns:

Concerning your Skin please indicate if you experience any of the following:

In respect to your Musculoskeletal System please indicate if you suffer from any of the stated bellow:

Regarding your Dental Health please indicate if you have any of the bellow:

About your Nutrition, please indicate if you consume any of the options indicated:

Please indicate any option that would apply to you:

Please indicate which fluids do you intake per day:

Please indicate the amount of fluids that you intake per day?

Continue on the next page...

Section 4 - Continuation

Lifestyle and Body Systems

Please fill in your sample dairy:

Sample Daily Menu

Breakfast:
Lunch:
Dinner:
Snacks:
Drinks:

Please upload the picture of your full tongue, like shown in the picture:

tongue analysis and consultation
Upload your picture...

Please upload the picture of your nails - both hands, no nail polish:

Health Analysis based on nails
Upload your picture...

Please, indicate if you have any questions or observations to add, before your consultation with Dr. Suraya Diaz:

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