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Dr. Suraya Diaz Clinic – Initial Questionnaire

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Initial Questionnaire

Dr. Suraya Diaz Clinic

Initial Consultation Questionnaire

Section 1

Personal Details
Form Submission Date
Select a date
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Name
Your Full Name
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Address
Your Address
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Date of Birth
Date of Birth
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Occupation
Occupation
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Telephone
Telephone
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Mobile number
Mobile
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Email
Your Email Address
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Referred by
Referred by
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Your Health

Your Height
please, specify your height in centimeters
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+
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Your Weight
Please, specify your weight in kilograms
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Number of Children
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Your Blood Type
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Martial Status
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Do we have permission to contact your GP?
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GP's Name
GP Name
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GP's Address
GP Address
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GP's Phone
GP Telephone
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Are you currently seeing any other practitioners?
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Please, describe briefly the work you have been doing with them.
Details...
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Section 2

Presenting Compliant/-s

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

Symptom 1
Enter First Symptom here...
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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
Please, tell me how severe your symptoms are.
Please, tell me how severe your symptoms are.
Symptom 2
Enter Second Symptom here...
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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
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...
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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
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)
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?
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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.
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Section 3

Previous Medical History

Please indicate your childhood diseases from the list below:

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

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Please describe them...
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Please indicate if you have any:

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

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Details...
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Section 4

Lifestyle and Body Systems

Regarding your lifestyle please indicate if you consume:

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Please indicate when did you started, the current quantity and periodicity...
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How many hours do you work per week on average?

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)
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:

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

Immunity
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Wellbeing
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Energy
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Do you generally feel cold or warm?
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Concerning your Cardiovascular System please indicate if you experience any of the described below:

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

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

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How regularly do you have bowel movements?

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Continue on the next page...

Section 4 - Continuation

Lifestyle and Body Systems

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

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Please indicate shape & size of stool type in the chart

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

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Please indicate any correct options regarding your Urinary System

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

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

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

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

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

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Continue on the next page...

Section 4 - Continuation

Lifestyle and Body Systems

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

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

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

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

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

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Please indicate any option that would apply to you:

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Please indicate which fluids do you intake per day:

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

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Continue on the next page...

Section 4 - Continuation

Lifestyle and Body Systems

Please fill in your sample dairy:

Sample Daily Menu

Breakfast:
Details...
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Lunch:
Details...
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Dinner:
Details...
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Snacks:
Details...
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Drinks:
Details...
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Please upload the picture of your full tongue, like shown in the picture:

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

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

Your final comments...
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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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