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
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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!
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QUESTIONNAIRES
CONSULTATION DOCUMENTS -
ADULTS 13+
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Medical & Health HISTORY
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Medical SYMPTOMS Questionnaire (MSQ)
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STRESS Assessment
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DIARY-JOURNAL - Diet, Nutrition, Lifestyle (7-day)
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+ STOOL Scale - Bristol Adult [REFERENCE]
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SLEEP Questionnaire
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ANXIETY Questionnaire (Hamilton Scale)
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Stress, Depression & Anxiety Questionnaire (IFM)
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MOOD-TYPE Questionniare
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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.
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Female HORMONE Balance Questionnaire
OR
FEMALE - Full Intake Questionnaire (FM17)
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TINNITUS Questionnaire
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DERMATOLOGY / Skin health issues CHART
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WOMAC Osteoarthritis Index
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SUPPLEMENT / MEDICATION SUMMARY
Please type up a list of all the medication & supplements you have / take - using this document - save and email back to Dr Adele
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CONSULTATION DOCUMENTS -
6-12 years old
History & Lifestyle Questionnaire
(Children 6-12 years old)
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7 day Diet & Nutrition Journal
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STOOL / POOP Scale - Bristol Children
CONSULTATION DOCUMENTS -
0-5 years old
History, Diet & Lifestyle Questionnaire
(Babies & Children 0-5 years old)
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STOOL / POOP Scale - Bristol Children
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STOOL / POOP Description - Baby Nappy
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