New Patient Form Dr K Part 1

Jeffrey M. Kucine D.O.

Back to Balance Osteopathic Wellness, LLC

107 Ridgely Ave. 14C Annapolis, MD 21401

(410) 263-3313

Name*

Age*

Date*

Date

What is your chief complaint? (Exact location of pain, if any)*

How long have you had it?

What caused it?

Sudden or gradual onset? Is it getting better or worse?

What have you done for it?

Have you had treatment for this complaint? If so, what?

Are you going to another doctor for treatment of any kind? If so, what for?

What medicine/medicines if any are you now taking?

Do you have any drug allergies? Other allergies?

Do you smoke?

Packs per day?

Do you drink alcoholic beverages?

How often?

List operations (including tonsils) and approximate date:

List serious illnesses you have had and approximate date.

Accidents - List approximate date and extent of injury.

List any traumas (Whiplash, falls, strain/sprains, fractures, etc.)

Have you had any x-rays and lab work done in the last 10 years? If so, what were you told about the results?

Are you suffering from any other complaints, other than what you described?

Type of employment?

Family History:

Gyn History

Pregnancies

YesNo

Children living

YesNo

Normal Menses

YesNo

Irregular Periods

YesNo

First day of last menstrual period

Last PAP and results

Breast Lumps

YesNo

Last complete physical exam:

When?

Date

Who?

Any significant findings?

Signature*