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Dr Kefalos's website and forms are Hippa Compliant.

Dr Kefalos’s website and forms are Hippa Compliant.

New Patient Questionnaire

  • Family History Section

 

Review of Systems. Please check off anything (C) that currently applies to you. Please mark (P) if something has been an issue in the past.

 

Fatigue:

 

Eyes

 

Ears

 

Nose / Sinuses:

 

Mouth:

 

Throat

 

Neck

 

Heart / circulation

 

Lungs:

 

Gastrointestinal (Stomach /Intestines)

 

Kidney/Urine:

  • For Men

 

Musculoskeletal:

 

Neurological

 

Endocrine:

 

Gynecologic (for women)

 

Skin/Nails

 

Blood

 

Vaccine History (Year)

 

Please list any other conditions you would like addressed

 

Habits

  • Please describe your typical meals:

 

Life situation

 

Hobbies/Interests

  • Please note: Many people, including Dr. Kefalos are allergic/sensitive to various fragrances. Please refrain from using scented skin and hair products when you visit us. Thank You!
 

Verification