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Dr. Kennedy's Educational Consultation Service Print E-mail
Questionnaire For Dr. Kennedy's Educational Consultation Service

After receipt of the completed forms below, Dr. Kennedy will evaluate your situation, do whatever research may be necessary and remit to you a report by letter, fax or e-mail. The total cost is $200 which can be paid by check, VISA, MasterCard, or Discover. If referral to a local doctor for further evaluation is indicated, Dr. Kennedy will recommend someone.

Dr. Kennedy's report to you will be as complete as he can make it. However, because this evaluation does not include a physical exam, nor a face-to-face interview, it is necessarily incomplete and therefore is recommended as an educational service, not a substitute for a full medical evaluation.

If you would like to submit your questionnaire and payment by mail, please fill out the forms online and you will be given the option of mailing the form from the payment page. You will be then presented with a printable page.

Name:
Address or PO Box:
City:
State:
Zip:
Home Phone Number:
Work Phone Number:
Fax Number:
Email Address:
Date of Birth:
Occupation:
Any Occupational Hazards:
If you are ill, the diagnosis you have been given
Please write a brief summary of your illness:
Date of last tests (blood, EKG, etc.):
Result of last tests:
Present meds:
Lifetime history of trauma or accident:
Pregnancy/delivery history:
Surgical history:
Family history - please mention blood relatives who have had any illness which may be the same or similar to yours:
Allergies (drugs, foods, airborne):
Tobacco use history:
Alcohol consumption history:
Lifetime history of caffeine use:
Lifetime history of use of non-prescription drug use:
Lifetime history of street drug use:
Symptoms which seem to come from your
Head:
Eyes:
Ears:
Nose:
Throat:
Heart:
Lungs:
Breasts:
Muscles:
Bones:
Upper digestive tract:
Lower digestive tract:
Nervous system (incoordination, imbalance, etc.):
Kidneys:
Bladder:
Genitals:
Arms and hands:
Legs and feet:
Neck:
Back:
Describe your sex drive within the context of what you consider normal for yourself:
Describe any abnormal findings doctors may have reported to you upon physical examination:
 
 



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