MEDICAL VISIT Initial Patient Consultation Questionnaire.
Please intend to give yourself 1/2 – 1 hour of quiet time to complete this questionnaire.
Asking the questions starts the process, even when we do not yet know the answers!
Please follow these guidelines while using the form :
Do not refresh or navigate away from the questionnaire page, or you will lose your entries and have to re-do the form. Please set aside 30-60 minutes to complete the form in one sitting (It might not take that long).
You can print your form out before submitting it. If you would like to print a copy of your completed form for your own use, do so and then submit.
When you are done, please use the submit button at the bottom of the page.
For people who are new patients having an Energy Medicine or Morphogenic Field Technique (kinesiology) visit only, the following questionnaire is to give Dr Kefalos a broad overview of your health. Please remember that this is not a medical visit; keep your answers brief!
Hours: Mon, Tues, Thurs ~ 9:30 – 4:30 Wed, Fri ~ 9:30-12:30
2455 NW Marshall Street, Suite 12 Portland, Oregon 97210
503-227-2200 / fax 503-227-5150
Fax direct to secure electronic medical record 503-470-7003