Pre-Consultation Questionnaire

Please set aside 15-20 minutes to fill out your pre-consultation questionnaire. Your answers contribute to Dr Miguel’s ability to provide you with the support you need. Thank you in advance for your time and effort.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How old are you?

Which of the following applies to you?

ADHD

Autism

Other neurodivergences

Anxiety

Depression

None of the above

Please list any conditions you live with

Please list any symptoms you experience with as a result of these conditions, and include their severity and how you tend to manage them

Please list all medications and supplements you are currently taking, including dosages.

Please list any known allergies or food sensitivities

Describe your typical daily diet, including typical meals and snacks

How many glasses of water you drink daily?

What does your current exercise routine look like?

Please provide details of exercise type, frequency and instensity

Describe your typical sleep patterns

Please include hours of sleep, sleep quality, and sleep disturbances

Do you wake up feeling refreshed?

Yes

How would you describe your current stress levels?

What methods you currently use to manage stress?

How do your current sypmtoms affect your daily life, work, and relationships?

Are your symptoms stopping you from doing something you enjoy?

Have you tried any treatments or strategies in the past to tackle your symptoms?

Please share what you've tried and how effective these strategies have been.

What are you hoping to get out of working with Dr Miguel?

What goals you expect to achieve out of your consultation?

Are there any other crucial facts you'd like to add for Dr Miguel to review before your appointment?

By submitting your pre-consultation questionnaire, you consent to the collection and use of your personal and health information for the purpose of the consultation(s) you’ve arranged with Dr Miguel Toribio-Mateas. You also confirm that you have read and agreed to the terms and conditions and the privacy policy regarding the handling of your personal and health information.

If you have agreed to provide Dr Miguel existing test results or clinical notes, you will be provided with an email address to send those to.