Pre-appointment questionnaire
Thank you for booking an appointment with Duffy Health. This short pre-appointment questionnaire is quick to complete and helps our practitioners better understand your needs, ensuring you get the most out of your appointment.
Full Name
*
First Name
Last Name
What is your date of birth?
*
Contact Number
-
Country Code (e.g. +44)
Phone Number
Email Address
*
example@example.com
What is the one most important issue you’d like to focus on?
When did it start? (Approximate timeframe – days, weeks, months or years)
How severe is this issue at its worst? On a scale of 1-10 where 10 is the worst (e.g., pain level, or level of stress/anxiety, etc.)
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Taking medications currently? (If yes, please give brief details)
Yes
No
Please list them.
Any medical history of major health concerns such as operations or chronic conditions? (If yes, brief description)
Yes
No
Please list them.
How is your sleep? On a scale of 1-10 where 10 is the worst.
Great
1
2
3
4
5
6
7
8
9
Bad
10
1 is Great, 10 is Bad
How is your appetite? On a scale of 1-10 where 10 is the worst.
Great
1
2
3
4
5
6
7
8
9
Bad
10
1 is Great, 10 is Bad
How is your energy levels generally? On a scale of 1-10 where 10 is the worst.
Great
1
2
3
4
5
6
7
8
9
Bad
10
1 is Great, 10 is Bad
Thank you for your time. We look forward to welcoming you in Clinic!
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