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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 – Intake & Consultation Form
Intake & Consultation Form
Dr. Suraya Diaz Clinic
Intake & Consultation Form
Section 1
PERSONAL DETAILS
Forename
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Surname
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Preferred Name
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Date of Birth
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Your Address
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Relationship Status
Single
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Relationship Status
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Occupation
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Your E-mail Address
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Telephone Number
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Emergency Contact Name
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Telephone Number
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Section 2
HEALTH
Doctor’s Name
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Doctor's Address
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Medication
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HEALTH PROBLEMS/Medical Conditions (Past & Current)
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Please indicate any option that would apply to you
Auditory / Visual hallucinations
Bipolar
Dissociative disorders
Personality disorders
Psychosis
Schizoaffective disorder
Schizophrenia
Epilepsy
Other
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Other, please indicate the name of your mental condition
Other, please indicate the name of your mental condition
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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 -
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Section 3
FROM THE LIST BELOW CIRCLE/TICK YOUR AREAS OF CONCERN
Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
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Anxiety
Stress
Fears
Phobias
Panic Attacks
Guilt
Relaxation
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Field is required!
Eating Problems
Food /Diet
Weight Problems
Anorexia
Bulimia
Exercise
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Depression
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
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Field is required!
Career Issues
Interview Skills
Nerves
Public Speaking
Concentration
Exams
Memory
Driving Skills
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Field is required!
Sexual Problems
Fertility
IVF
Conception
Pregnancy
Birth
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Field is required!
Pain Control
Hearing
Sight/Vision
Mobility
Skin Problems
Hair Growth
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Relationships
Childhood Problems
Sleep Problems
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Section 4
INTAKE/NOTES
Presenting Problem
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Symptoms/ Triggers/Habits
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Childhood memories related to the presenting problem?
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What do you want?
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What will your life be without the problem?
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Please make sure you read and understand the
Terms of Engagement & Consent
to proceed.
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Terms of Engagement & Consent
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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