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Dr. Suraya Diaz Clinic – Intake & Consultation Form

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Intake & Consultation Form

Dr. Suraya Diaz Clinic

Intake & Consultation Form

Section 1

PERSONAL DETAILS
Forename
Field is required!
Field is required!
Surname
Field is required!
Field is required!
Preferred Name
Field is required!
Field is required!
Date of Birth
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
  • Relationship Status
  • Single
  • Married
  • Widowed
  • Divorced
Relationship Status
Field is required!
Field is required!
Occupation
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Telephone Number
Invalid phonenumber!
Invalid phonenumber!
Emergency Contact Name
Field is required!
Field is required!
Telephone Number
Invalid phonenumber!
Invalid phonenumber!

Section 2

HEALTH
Doctor’s Name
Field is required!
Field is required!
Doctor's Address
Field is required!
Field is required!
Medication
Field is required!
Field is required!
HEALTH PROBLEMS/Medical Conditions (Past & Current)
Field is required!
Field is required!
Please indicate any option that would apply to you
Field is required!
Field is required!
Other, please indicate the name of your mental condition
Other, please indicate the name of your mental condition
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 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!

Section 3

FROM THE LIST BELOW CIRCLE/TICK YOUR AREAS OF CONCERN
Addictions
Field is required!
Field is required!
Anxiety
Field is required!
Field is required!
Eating Problems
Field is required!
Field is required!
Depression
Field is required!
Field is required!
Career Issues
Field is required!
Field is required!
Sexual Problems
Field is required!
Field is required!
Pain Control
Field is required!
Field is required!
Relationships
Field is required!
Field is required!

Section 4

INTAKE/NOTES
Presenting Problem
Field is required!
Field is required!
Symptoms/ Triggers/Habits
Field is required!
Field is required!
Childhood memories related to the presenting problem?
Field is required!
Field is required!
What do you want?
Field is required!
Field is required!
What will your life be without the problem?
Field is required!
Field is required!
Please make sure you read and understand the Terms of Engagement & 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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