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Dr. Suraya Diaz Clinic – Consultation Follow Up Questionnaire

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Consultation Follow Up Questionnaire

Dr. Suraya Diaz Clinic

Measure Yourself Medical Outcome Profile

Patient's Name:

Enter Your Full Name
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Enter Your Email Address
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Please answer the following questions:

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

Symptom 1...
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Rate from 1 (as good as it could be) to 6 (as bad as it could be) - IN THE LAST WEEK
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Symptom 2...
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Rate from 1 (as good as it could be) to 6 (as bad as it could be) - IN THE LAST WEEK
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Name an activity in your live that has been affected by these symptoms?

Affected Activity...
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Rate from 1 (as good as it could be) to 6 (as bad as it could be) - IN THE LAST WEEK
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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)
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Are you taking medication for these problems?

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Please write in name of medication, and how much a day / week.
Details...
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If an important new symptom has appeared, please describe it and mark how bad it is below. Otherwise do not use this line.

Describe the new symptom...
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Rate from 1 (as good as it could be) to 6 (as bad as it could be)
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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:

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

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

Details...
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What colour do you pick today. What colour draws you attention the most today?

example: A12
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What is your favourite colour? For example what colour do you choose to wear or decorate your house or buy items?

example: A12
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What colour you really don’t like?

example: A12
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Please make sure you read and understand the Terms of Engadgement & Consent to proceed.
You have to read and agree to the Terms of Engagement and Consent to proceed to submit your questionnaire.
You have to read and agree to the Terms of Engagement and Consent to proceed to submit your questionnaire.
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About

A Natural Life

Based in Galway, Ireland, Dr. Suraya Diaz has dedicated her life to the science of good health and has recently launched ‘A Natural Life’, a line of healthy all natural products to help people regain control, health and happiness.
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