MFT Visit - DR. KIRANA KEFALOS, M.D., L.L.C. Portland OR. Internal Medicine from a Holistic Perspective © 2015DR. KIRANA KEFALOS, M.D., L.L.C. Portland OR. Internal Medicine from a Holistic Perspective © 2015

Dr Kefalos’s website and forms are Hippa Compliant.

Name *
Date of Appointment In this format (03/03/2015)
Date of Birth *
Significant Past Medical History
Significant Past Surgical History
Drug Allergies
Non drug allergies or sensitivities (such as foods, plants, chemicals)
Current Prescription medications and OTC (over the counter) drugs
Current nutritional supplements, homeopathy
Please list your top 3 symptoms/health concerns
Please give a brief background on each of them, such as how long they have been troubling you and what you have done in the past to improve the above conditions (if anything)
In a few sentences, please describe your typical diet (you eat out a lot, you are vegetarian/vegan etc)
How much water/day do you drink?
How much caffeine /day do you drink?
How much alcohol/week do you drink?
Do you eat sweets most days?
YesNo
Where did you hear about Dr Kefalos?