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Home
About
Health Consultancy & Test
Book a Consultancy
Nutrition
Specialised Hypnotherapy
Mindset Therapy
Rapid Transformational Therapy
Homeopathy
Bioresonance
Herbal Medicine
Naturopathy
Consultation Packages
Health Tests
Shop
Natural Products
Apple Cider Vinegar
Food Products
Probiotic Drinks
Natural Supplements
Pets Food Supplements
Herbal Products
Herbal Teas
Herbs
Herbal Blends
Individual Herbs
Herbal Glycerates & Syrup
Health Aims
Stress & Mood
Sleep Support
Brain Support
Immunity Support
Fertility
Skin Hair and Nails
Gut Support
Slim and Detox Support
Digestive Support
Energy Support
Information
Frequently Ask Questions
Shipping and Delivery Information
Other Products
Gift Cards
Latest News
Contact Us
Dr. Suraya Diaz Clinic – Initial Questionnaire
Initial Questionnaire
Dr. Suraya Diaz Clinic
Initial Consultation Questionnaire
Section 1
Personal Details
Form Submission Date
Select a date
Field is required!
Field is required!
Name
Your Full Name
Field is required!
Field is required!
Address
Your Address
Field is required!
Field is required!
Date of Birth
Date of Birth
Field is required!
Field is required!
Occupation
Occupation
Field is required!
Field is required!
Telephone
Telephone
Field is required!
Field is required!
Mobile number
Mobile
Field is required!
Field is required!
Email
Your Email Address
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Field is required!
Referred by
Referred by
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Field is required!
Your Health
Your Height
please, specify your height in centimeters
-
+
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Field is required!
Your Weight
Please, specify your weight in kilograms
-
+
Field is required!
Field is required!
Number of Children
-
+
Field is required!
Field is required!
Your Blood Type
0
A
B
AB
Field is required!
Field is required!
Martial Status
Single
Married
Divorced
Widowed
Field is required!
Field is required!
Do we have permission to contact your GP?
Yes
No
Field is required!
Field is required!
GP's Name
GP Name
Field is required!
Field is required!
GP's Address
GP Address
Field is required!
Field is required!
GP's Phone
GP Telephone
Field is required!
Field is required!
[{"field":"contact_gp","logic":"equal","value":"yes","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Are you currently seeing any other practitioners?
Yes
No
Field is required!
Field is required!
Please, describe briefly the work you have been doing with them.
Details...
Field is required!
Field is required!
[{"field":"Other_Practitioners","logic":"equal","value":"yes","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Please rate from 1 (as good as it could be) to 6 (as bad as it could be). How ready are you to make changes in your life to improve your presenting problem?
- select a option -
1
2
3
4
5
6
- select a option -
Field is required!
Field is required!
What colour do you pick today. What colour draws you attention the most today?
Click to view the colour chart
example: A12
Field is required!
Field is required!
What is your favourite colour? For example what colour do you choose to wear or decorate your house or buy items?
Click to view the colour chart
example: A12
Field is required!
Field is required!
What colour you really don’t like?
Click to view the colour chart
example: A12
Field is required!
Field is required!
Section 2
Presenting Compliant/-s
What are the two main concerns that bring you to this clinic?
Symptom 1
Enter First Symptom here...
Field is required!
Field is required!
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
1
2
3
4
5
6
Please, tell me how severe your symptoms are.
Please, tell me how severe your symptoms are.
Symptom 2
Enter Second Symptom here...
Field is required!
Field is required!
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
1
2
3
4
5
6
Please, tell me how severe your symptoms are.
Please, tell me how severe your symptoms are.
What activity in your life has been affected by these symptoms?
Activity
Enter activity that has been affected here...
Field is required!
Field is required!
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
1
2
3
4
5
6
Please, tell me how severe your symptoms are.
Please, tell me how severe your symptoms are.
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)
1
2
3
4
5
6
Please, tell me how severe your symptoms are.
Please, tell me how severe your symptoms are.
Are you currently taking any prescribed or self-administered medication?
Yes
No
Field is required!
Field is required!
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...
Tell me about all medication/ supplements & herbs you are currently taking.
[{"field":"Other_Medications","logic":"equal","value":"yes","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Field is required!
Field is required!
[{"field":"Other_Medications","logic":"equal","value":"yes","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Section 3
Previous Medical History
Please indicate your childhood diseases from the list below:
Chickenpox
Coughs and colds
Ear infections in children
Croup
Diarrhea and vomiting
Fever in children
Measles
Mumps
Other
Field is required!
Field is required!
Details...
[{"field":"Childhood_Diseases","logic":"equal","value":"Other","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Field is required!
Field is required!
Did you have any major/ recurrent illnesses during your life?
Yes
No
Field is required!
Field is required!
Please describe them...
[{"field":"major_diseases","logic":"equal","value":"yes","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Field is required!
Field is required!
Please indicate if you have any:
Allergies
Accidents
Hospitalizations
Surgery
Does not apply
Field is required!
Field is required!
Details...
[{"field":"medical_history_chkbx","logic":"equal","value":"Allergies","and_method":"","field_and":"date","logic_and":"","value_and":""},{"field":"medical_history_chkbx","logic":"equal","value":"Accidents","and_method":"","field_and":"date","logic_and":"","value_and":""},{"field":"medical_history_chkbx","logic":"equal","value":"Hospitalizations","and_method":"","field_and":"date","logic_and":"","value_and":""},{"field":"medical_history_chkbx","logic":"equal","value":"Surgery","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Field is required!
Field is required!
Regarding your health family history, what are the major health problems in your family, including major health details of grandparents, parents and siblings:
Cardiovascular Disease
Cancer
Diabetes
Thyroid or adrenal problems
Respiratory problems
Skin conditions
Depression or anxiety
Other
Field is required!
Field is required!
Details...
[{"field":"Family_Diseases","logic":"equal","value":"Other","and_method":"","field_and":"date","logic_and":"","value_and":""}]
Field is required!
Field is required!
Section 4
Lifestyle and Body Systems
Regarding your lifestyle please indicate if you consume:
Tobacco
Alcohol
Caffeine: coffee or tea (black or green)
Recreational drugs
Other
Field is required!
Field is required!
Please indicate when did you started, the current quantity and periodicity...
Field is required!
Field is required!
How many hours do you work per week on average?
between 10 and 25 hours
between 30-40 hours
between 40-60 hours
more than 60 hours
Please specify the average hours you work each week.
Please specify the average hours you work each week.
Please rate your job satisfaction:
(1 as good as it could be), 6 (as bad as it could be)
1
2
3
4
5
6
Please, tell me how happy are you with your job.
Please, tell me how happy are you with your job.
Please indicate the affirmations that apply to you:
My job is stressful
I do have a good work-life balance
I do perform physical exercise at least 3 times per week
I have hobbies and pastimes
Field is required!
Field is required!
How would you rate your general Immunity / infections, wellbeing and energy?
Immunity
1
2
3
4
5
6
Field is required!
Field is required!
Wellbeing
1
2
3
4
5
6
Field is required!
Field is required!
Energy
1
2
3
4
5
6
Field is required!
Field is required!
Do you generally feel cold or warm?
Warm
Cold
Field is required!
Field is required!
Concerning your Cardiovascular System please indicate if you experience any of the described below:
Cardiovascular diagnosed health problem
Chest pains
Shortness of breath
Cold hands/feet
Ankle oedema
Varicose veins
Orthopnoea
No Cardiovascular system problems
Field is required!
Field is required!
Concerning your Respiratory System please indicate if you experience any of the described below:
Cough
Nose or cough bleeds
Difficulty in inhaling/exhaling
Wheeze
Mucus or sputum
Issues with ears
Issues with nose
Issues with throat
Respiratory diagnosed health problem
No respiratory problems
Field is required!
Field is required!
Concerning your Digestive System please indicate if you experience any of the described below:
Good appetite
Indigestion
Acid reflux
Difficulty in swallowing
Nausea / vomit
Abdominal pain
Bloating or gas
Hemorrhoids
Digestive diagnosed health problem
No digestive system problems
Field is required!
Field is required!
How regularly do you have bowel movements?
once per day or more
every two days
every three days
more than three days apart
Field is required!
Field is required!
Continue on the next page...
Section 4 - Continuation
Lifestyle and Body Systems
What is the color of your stool? Please indicate any correct option
Light Brown
Brown
Dark Brown
Blood in stool: bright red
Blood in stool: dark red
Field is required!
Field is required!
Please indicate shape & size of stool type in the chart
Click to View the stool chart
<a href="http://naturallifebydrdiaz.com/wp-content/uploads/2022/02/bristolstoolchart.pdf" title="view Stool Chart" target="_blank">Click to View the stool chart</a>
<a href="http://naturallifebydrdiaz.com/wp-content/uploads/2022/02/bristolstoolchart.pdf" title="view Stool Chart" target="_blank">Click to View the stool chart</a>
Field is required!
Field is required!
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Field is required!
Field is required!
Regarding your Urinary System, please indicate the color of your urine in the middle of the day.
Click to view the urine chart
<a href="http://naturallifebydrdiaz.com/wp-content/uploads/2022/02/Urine-Chart.pdf" title="view urine chart" target="_blank">Click to view the urine chart</a>
<a href="http://naturallifebydrdiaz.com/wp-content/uploads/2022/02/Urine-Chart.pdf" title="view urine chart" target="_blank">Click to view the urine chart</a>
Field is required!
Field is required!
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Type 8
Field is required!
Field is required!
Please indicate any correct options regarding your Urinary System
Urgency, pain, burning or loin pain during urination
Blood in your urine: bright red
Blood in your urine: dark red
Incontinence
Nocturia
No problems with the urinary System
Field is required!
Field is required!
Regarding your Reproductive system please indicate please if you experience any of the following
Pain while having sexual intercourse
Suffers from a reproductive dysfunction
Good libido
Sexual Transmitted Diseases
None of the above
Field is required!
Field is required!
Regarding FEMALE Reproductive system, please indicate the length of your menstrual cycle:
Does not apply
Less than 21 days
Between 22 and 25 days
Between 26 and 28 days
Between 27 and 32 days
More than 33 days
Field is required!
Field is required!
Regarding a FEMALE Reproductive system, please indicate any correct option:
Does not apply
Regular menstrual cycle
Suffers from premenstrual tension
Pain during your menstrual cycle
Clots in the period
Suffers from fibroids, ovarian cysts or endometriosis
Fertility issues
Good smear
Pregnancies
Miscarriages, terminations
Menopause
Blood is mainly bright red during the period
Blood is mainly dark red during the period
Field is required!
Field is required!
Regarding FEMALE Reproductive system, please indicate the color(s) of your blood during your period:
Click to view the blood chart
<a href="http://naturallifebydrdiaz.com/wp-content/uploads/2022/02/Blood-colour-chart.pdf" title="view blood chart" target="_blank">Click to view the blood chart</a>
<a href="http://naturallifebydrdiaz.com/wp-content/uploads/2022/02/Blood-colour-chart.pdf" title="view blood chart" target="_blank">Click to view the blood chart</a>
Field is required!
Field is required!
Does Not Apply
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Field is required!
Field is required!
Concerning your Nervous System please indicate any option that would apply to you:
Good mood
Anger, sadness, depression
Anxiety
Stress
Good short-term memory
Good long-term memory
Faint
Headaches
Numbness
Visual disturbances
Dizziness
Hearing loss/ tinnitus
None of the above
Field is required!
Field is required!
Continue on the next page...
Section 4 - Continuation
Lifestyle and Body Systems
Please indicate the options that most apply to your sleep patterns:
Sleeps less than 7 hours
Sleeps between 7 and 8 hours
Sleeps more than 8 hours
Fall asleep easily
Work night shifts
Rested after a night of sleep
Disturbed sleep
Night sweats
Field is required!
Field is required!
Concerning your Skin please indicate if you experience any of the following:
Acne
Skin rashes
Itching skin
Eczema
Psoriasis
Good wound healing time
Fungal infections
Herpes
Use organic skin care products and detergents
None of the above
Field is required!
Field is required!
In respect to your Musculoskeletal System please indicate if you suffer from any of the stated bellow:
Joint or muscle pain
Cramps
Spams
Stiffness
Swelling
Back pain
Poor hair and nail quality
None of the above
Field is required!
Field is required!
Regarding your Dental Health please indicate if you have any of the bellow:
Mercury fillings
Root canals
Good teeth health
Field is required!
Field is required!
About your Nutrition, please indicate if you consume any of the options indicated:
Dairy
Wheat
Gluten
Meat
Fish
Animal Products
Sugar
Processed foods
Mainly organic food
Field is required!
Field is required!
Please indicate any option that would apply to you:
Good relationship with food
Good cooking habits
Suffers from eating disorders
Have salty food cravings
Field is required!
Field is required!
Please indicate which fluids do you intake per day:
Regular Tea
Herbal Tea
Coffee
Water
Cow's Milk
Alcohol
Fizzy Drinks
Field is required!
Field is required!
Please indicate the amount of fluids that you intake per day?
Less than 1liter
Between 1 and 1.5 liters
Between 1.5 and 2 liters
Between 2 and 2.5 liters
More than 2.5 liters
Field is required!
Field is required!
Continue on the next page...
Section 4 - Continuation
Lifestyle and Body Systems
Please fill in your sample dairy:
Sample Daily Menu
Breakfast:
Details...
Field is required!
Field is required!
Lunch:
Details...
Field is required!
Field is required!
Dinner:
Details...
Field is required!
Field is required!
Snacks:
Details...
Field is required!
Field is required!
Drinks:
Details...
Field is required!
Field is required!
Please upload the picture of your full tongue, like shown in the picture:
Upload your picture...
There was a problem with the file upload.
There was a problem with the file upload.
Please upload the picture of your nails - both hands, no nail polish:
Upload your picture...
There was a problem with the file upload.
There was a problem with the file upload.
Please, indicate if you have any questions or observations to add, before your consultation with Dr. Suraya Diaz:
Your final comments...
Field is required!
Field is required!
Please make sure you read and understand the
Terms of Engagement & Consent
to proceed.
I have read and understand the
Terms of Engagement & Consent
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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