QUESTIONNAIRES | Dr Adele Pelteret

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

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

ANXIETY Questionnaire (Hamilton Scale)

Stress, Depression & Anxiety Questionnaire (IFM)

MOOD-TYPE Questionniare

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

DERMATOLOGY / Skin health issues CHART

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.

You can also complete a detailed list on the CONSENT FORM

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HOW TO

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

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