DR ADELE PELTERET - Naturopath
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Print and Complete
Once completed, please scan and email these back to me, at least 2 FULL WORKING DAYS before your consultation.
* if you are coming for an IN-PRACTICE / FACE-TO-FACE (F2F) consultation - BRING these WITH YOU!
OR
Complete on a PDF editor (OR some can be completed in EXCEL)
Once completed, please email these back to me, at least 2 FULL WORKING DAYS before your consultation.
Make sure the lighting and focus are GOOD please!
* if you are coming for an IN-PRACTICE / FACE-TO-FACE (F2F) consultation - BRING these WITH YOU!
QUESTIONNAIRES
Only complete the questionnaires Dr Adele has requested from you
CONSULTATION DOCUMENTS -
ADULTS 13+
Medical & Health HISTORY
Medical SYMPTOMS Questionnaire (MSQ)
STRESS Assessment
DIARY-JOURNAL - Diet, Nutrition, Lifestyle (7-day)
+ STOOL Scale - Bristol Adult [REFERENCE]
SLEEP Questionnaire
Depression, Anxiety and Stress Questionnaire (DASS 21)
Patient Health Questionnaire and General Anxiety Disorder
(PHQ-9 and GAD-7)
BODY PAIN CHART
Please print and shade or mark the areas where your pain is most common - use the pain scale to "rate" your pain levels in each area.
Alopecia - Hairloss Questionnaire
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Female HORMONE Balance Questionnaire
FEMALE - Intake Questionnaire (FM17)
Menopause rating scale
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TINNITUS Questionnaire
DERMATOLOGY / Skin health issues CHART
WOMAC Osteoarthritis Index
MALE - Intake Questionnaire (FM15)
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SUPPLEMENT / MEDICATION SUMMARY
Please type up a list of all the medication & supplements you have / take - using this document template - save and then email it back to Dr Adele.
You can also complete a detailed list on the CONSENT FORM
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OR
CONSULTATION DOCUMENTS -
6-12 years old
History & Lifestyle Questionnaire
(Children 6-12 years old)
7 day Diet & Nutrition Journal
STOOL / POOP Scale - Bristol Children
Short MOOD & FEELINGS Questionnaire (Ages 6-17) - PARENT
Short MOOD & FEELINGS Questionnaire (Ages 6-17) - CHILD
CONSULTATION DOCUMENTS -
0-5 years old
History, Diet & Lifestyle Questionnaire
(Babies & Children 0-5 years old)
STOOL / POOP Scale - Bristol Children
STOOL / POOP Description - Baby Nappy