DR. KIRANA KEFALOS, M.D., L.L.C. Portland OR. Internal Medicine from a Holistic Perspective © 2015
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Dr Kefalos’s website and forms are Hippa Compliant.
New Patient Questionnaire
Appointment Date
In this format (03/03/2012)
Name
*
Date of birth
*
Your age
Family History Section
Father's Name
1. Alive or Deceased now? 2. Year of Birth 3. Health conditions, Cause of Death. 4. Age at Death
Mothers Name
1. Alive or Deceased now? 2. Year of Birth 3. Health conditions, Cause of Death. 4. Age at Death
Please list your Siblings (if any)
(Male or Female), Name, Year of Birth, Health conditions, Cause of Death (age at death)
Please list your Children (if any)
(Male or Female), Name, Year of Birth, Health conditions, Cause of Death (age at death)
Partner / Spouse
(Male or Female), Name, Year of Birth, Health conditions, Cause of Death (age at death)
Illnesses that 'run in the family'
Past medical problems
Please list significant past medical problems, major illnesses and hospitalizations, with dates
Injuries and surgeries
Please list injuries and surgeries with dates. Please indicate if any of these still bother you.
Transfusion
*
Have you ever had a blood transfusion?
no
yes
If yes (date)
Special tests xrays
Please list any special tests xrays that you have had
Current medical problems. Please list them in the order of their importance to you.
Current Prescriptions
Please give names and dosages
Supplements, Vitamins and OTC Medicines
Please list all supplements and vitamins that you are currently taking (with dosages)
Cortisone, Prednisone or other steroid treatments
Have you ever received cortisone, prednisone or other steroid treatments? If so, please indicate why, when, how much and for how long.
How many courses of antibiotics have you taken in the past 3 years?
How many courses of antibiotics have you taken in your lifetime (estimate)
Please list any drug allergies you have
Please list any non drug allergies or sensitivities (such as foods, plants, chemicals)
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.
I feel great
(C)
(P)
I feel Ok
(C)
(P)
I don't feel so good
(C)
(P)
I feel pretty bad
(C)
(P)
Additional Comments
Recent weight loss amount
Current or past
(C)
(P)
Recent weight gain amount
Current or Past
(C)
(P)
Fever: I get colds and flu easily and/or often
yes
Current or Past
(C)
(P)
Decline in general health
(C)
(P)
Additional Comments
Fatigue:
I feel fatigued and run down
Yes?
Current or past
(C)
(P)
If Yes, since
What is contributing to your fatigue?
Current or Past
(C)
(P)
If you have fatigue: Is it worse in:
morning
afternoon
evening
after meals
Additional comments
Eyes
Redness
(C)
(P)
Pain
(C)
(P)
Dryness
(C)
(P)
Wear Eyeglasses
(C)
(P)
Glaucoma
(C)
(P)
Cataracts
(C)
(P)
Date of last eye exam
Additional comments
Ears
Loss of hearing
(C)
(P)
Wax buildup
(C)
(P)
Pain
(C)
(P)
Drainage
(C)
(P)
History of ear infections
(C)
(P)
Additional comments
Nose / Sinuses:
Nosebleeds
(C)
(P)
Snoring
(C)
(P)
Sleep apnea
(C)
(P)
Postnasal drip
(C)
(P)
Environmental / seasonal allergies
(C)
(P)
Sinus infections
(C)
(P)
Chronic congestion
(C)
(P)
Additional comments
Mouth:
Sores in mouth
(C)
(P)
I see a dentist regularly
(C)
(P)
Dentures (false teeth)
(C)
(P)
Bad breath
(C)
(P)
Gum problems
(C)
(P)
Herpes / cold sores
(C)
(P)
Pain
(C)
(P)
Additional comments
Throat
Hoarseness
(C)
(P)
Difficulty swallowing
(C)
(P)
Voice changes
(C)
(P)
Additional comments
Neck
Goiter (enlarged thyroid)
(C)
(P)
Swollen glands
(C)
(P)
Pain
(C)
(P)
Stiffness
(C)
(P)
Additional comments
Heart / circulation
High blood pressure since year
High cholesterol since year
History of heart attack year
Heart valve problem
(C)
(P)
Mitral Valve Prolapse
(C)
(P)
Murmur
(C)
(P)
Chest pain
(C)
(P)
Irregular heart beat
(C)
(P)
Swelling of feet/legs
(C)
(P)
Have you had either an EKG (electrocardiogram)or an echocardiogram (ultra-sound test on heart)? (Date)
I have had a stress test (date)
Findings
I have had a heart catheterization (date)
Findings
Leg cramps if walk a certain distance
(C)
(P)
Raynauds
(fingers or toes are very cold and/or sometimes turn blue or white)
(C)
(P)
Additional comments
Lungs:
Recurrent /chronic bronchitis
(C)
(P)
Shortness of breath
(C)
(P)
Asthma
(C)
(P)
Cough
(C)
(P)
Smokers cough
(C)
(P)
Pain
(C)
(P)
Additional comments
Gastrointestinal (Stomach /Intestines)
Nausea
(C)
(P)
Vomiting
(C)
(P)
Vomiting blood
(C)
(P)
Abdominal pain
(C)
(P)
Bloating
(C)
(P)
Indigestion/heartburn/GERD
(C)
(P)
Belching
(C)
(P)
Gas (flatulence)
(C)
(P)
Antacid use
(C)
(P)
Anti-inflammatory drug use (Aspirin, Advil, Aleve, Ibuprofen)
(C)
(P)
Ulcer
(C)
(P)
Constipation
(C)
(P)
Diarrhea
(C)
(P)
Rectal pain
(C)
(P)
Jaundice
(C)
(P)
Hepatitis
(C)
(P)
I use laxatives regularly
(C)
(P)
Straining with stool
(C)
(P)
Additional comments
How often do you pass stool?
My stools look like
pale
light brown
dark brown
green
black
hard pellet
firm log
loose
watery
mucous-y
Additional comments
Blood in stools
(C)
(P)
Hemorrhoids
(C)
(P)
I have had a colonoscopy (date)
Findings
Additional comments
Kidney/Urine:
Pain/burning on urination
(C)
(P)
Blood in urine
(C)
(P)
Cloudy, smokey urine
(C)
(P)
Frequent urination
(C)
(P)
Frequent urine infections
(C)
(P)
Incontinence
(C)
(P)
Kidney stones
(C)
(P)
For Men
Enlarged prostate
(C)
(P)
Prostate cancer
(C)
(P)
Erection difficulties
(C)
(P)
Difficultly starting stream
(C)
(P)
Difficulty stopping stream/dribbling
(C)
(P)
Additional comments
Musculoskeletal:
Muscle Pain
Yes
(C)
(P)
Joint pain
Yes
(C)
(P)
Swollen joints
Yes
(C)
(P)
Neck pain / spasm
Yes
(C)
(P)
Back pain
Yes
(C)
(P)
Decreased range of motion
Yes
(C)
(P)
Please explain
Arthritis
Yes
(C)
(P)
Which joints?
Lupus
Yes
(C)
(P)
When diagnosed?
Lyme disease
Yes
(C)
(P)
When Diagnosed?
Fibromyalgia
Yes
(C)
(P)
Cramps
Yes
(C)
(P)
Leg cramps at night
Yes
(C)
(P)
Additional comments
Neurological
Headaches
Yes
(C)
(P)
Migraines
Yes
(C)
(P)
How Often?
Visual changes
Please explain
Brain fog
(C)
(P)
Panic attacks
(C)
(P)
Feel hostile and angry
(C)
(P)
Numbness
(C)
(P)
Tingling
(C)
(P)
Dizziness
(C)
(P)
Fainting spells / loss of balance
(C)
(P)
Seizures
(C)
(P)
Facial pain
(C)
(P)
Depression
(C)
(P)
Anxiety
(C)
(P)
Tremors
(C)
(P)
Memory loss
(C)
(P)
Additional comments
Endocrine:
Low blood pressure
(C)
(P)
Diabetes (high sugar)
diet controlled
oral meds
insulin
Metabolic syndrome
(C)
(P)
Hypoglycemia (low sugar)
(C)
(P)
Hypothyroid (under active thyroid)
(C)
(P)
Hyperthyroid (over active thyroid)
(C)
(P)
Thyroid surgery (date)
Insomnia
(C)
(P)
I can't fall asleep
(C)
(P)
I can't stay asleep
(C)
(P)
I sleep well and wake up rested
(C)
(P)
Number of hours of sleep I currently get on a regular basis
Number of hours of sleep I used get when I was younger
Additional comments
Gynecologic (for women)
My Gynecologist is Dr.
Regular menstrual cycles
(C)
(P)
Have cycle every ? days
Irregular menstrual cycles
(C)
(P)
Heavy bleeding
(C)
(P)
Painful menstrual cramps
(C)
(P)
I am peri-menopausal
(C)
(P)
I am menopausal
(C)
(P)
Vaginal discharge
(C)
(P)
Vaginal itch
(C)
(P)
Vaginal dryness
(C)
(P)
Hot flashes
(C)
(P)
Breast lump or mass
(C)
(P)
Breast cancer
Yes
(C)
(P)
When Diagnosed (Year)
Treated with
surgery
chemotherapy
radiation
Gynecologic cancer
yes
(C)
(P)
When Diagnosed (Year)
Painful intercourse
(C)
(P)
Bleeding after intercourse
(C)
(P)
Decreased libido
(C)
(P)
PMS
(C)
(P)
Bone density scan (date )
Findings
Osteoporosis
(C)
(P)
Last menstrual period
Last mammogram
Last PAP smear findings
Additional comments
Skin/Nails
Rash
(C)
(P)
Dryness
(C)
(P)
Itching
(C)
(P)
Nodules / Bumps
(C)
(P)
Ringworm / Fungus
(C)
(P)
Toenail fungus
(C)
(P)
Eczema
(C)
(P)
Psoriasis
(C)
(P)
Acne
(C)
(P)
Have received antibiotics for acne
(C)
(P)
Hair loss
(C)
(P)
Treatments used
Additional comments
Blood
Anemia
(C)
(P)
Bleeding tendency
(C)
(P)
Other blood disease
Your blood type
Additional comments
Vaccine History (Year)
dT
dPT
Annual flu
Pneumovax
Gardisil (HPV)
Herpes
Other
Please list any other conditions you would like addressed
Other not listed
Habits
Tobacco use:
never
(C)
(P)
Age started
Age quit
Packs a day
Alcohol use:
never
(C)
(P)
Recreational drug use:
never
(C)
(P)
Caffeine as soda/coffee/tea
(C)
(P)
If yes to caffeine soda/coffee/tea, how much?
Chocolate/sweets how much
Artificial sweeteners
Yes
No
Fruits/vegetables eaten daily
Do you eat
red meat
chicken
fish
What foods do you crave?
What foods are you allergic or intolerant to?
How do you feel if you miss a meal or eat a meal later than usual?
Please describe your typical meals:
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Water: amount ingested daily
Do you exercise?
Did you ever exercise on a regular basis?
What is your chosen form of exercise?
Have you ever had an HIV/AIDS test?
Yes
No
Year
Results
Have you ever had an STD (sexually transmitted disease)
Yes
No
Do you have a satisfying sexual life?
Yes
No
Do you enjoy sex with
men
women
both
Have you ever experienced domestic violence
yes
no
Have you ever been sexually assaulted
yes
no
Do you have a satisfying spiritual life
yes
no
Do you meditate/pray/spend time in silence
yes
no
Have you ever
yes
no
Do you feel connected to the sacred
yes
no
If so what allows this to occur
You consider your stress level, in general to be
Are you having any body work/energy work done (chiropractic, colonic, massage, acupuncture, etc)
Have you in the past?
My practitioner is
Life situation
Where have you traveled and become ill (bad diarrhea etc.)
If so, please indicate where, when and ill in what way. Do you feel fully recovered?
Do you have a partner/spouse
Do you live with your partner?
How long?
Are you employed?
What do you do?
List up to 3 adjectives to describe your feelings about your work or weekday activities
What activity engages most of your time on the weekends?
List up to three adjectives to describe your weekend activities
Do you participate in expressive or creative activities? What do you do that is creative /expressive? (examples: music, arts, crafts, dance, sewing, knitting, writing) How often do you do this (times/week or times/month)?
Hobbies/Interests
List up to 5 positive attributes regarding your current life situation
List up to 5 negative attributes regarding your current life situation if any.
Are you suffering?
If so what is the cause of your suffering?
If you had a Mission Statement right now it would be ~
How did you hear about Dr. Kefalos
Please let me know how you came to hear about us.
Email
*
Please enter your email. You will receive an email shortly, confirming I have received your questionnaire.
Privacy statement and your acceptance
I have read and agree to the Privacy page at http://drkefalos.com/privacy/ and agree that submission of this form constitutes your agreement with Hippa privacy practices.
YES, I agree
NO, I do not agree
Thank you for taking the time today to complete this questionnaire.
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!
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