Pullman Family Medicine
915 NE Valley Rd
Pullman, WA 99163
Phone: (509) 332-3548
Fax: (509) 332-5253

Pullman Family Medicine Health History Questionnaire

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Fill-out the form below and then print it out. Your information will not be saved or sent.
Thank you for your interest in our practice. We ask new patients to complete this form. All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name:
Date of Birth:
Address:
Phone:
-
Date of last primary care visit:
Who would you like to see? (Specify if preference. Leave blank if no preference):
Main reason(s) you would like to be seen: (Indicate if L&I related)
Current medical conditions: (Indicate if L&I related)
Past medical conditions/ surgeries (no longer requiring treatment):

Review of Systems – Please list briefly any current symptoms

Skin:
Head/Neck:
Throat:
Lungs:
Chest/Heart:
Back or joints:
Intestinal:
Bladder:
Circulation:
Other:

Describe any recent changes in:

Weight:
Mood:
Energy level:
Other concern:

Allergies to Medications

Medication Name / Reaction / Comments:
Medication Name / Reaction / Comments: (2)
Medication Name / Reaction / Comments: (3)
Medication Name / Reaction / Comments: (4)

Current medications- List all prescriptions, over the counter drugs, vitamins and supplements

Name of Medication / Strength (Dose) / How often taken?
Name of Medication / Strength (Dose) / How often taken? (2)
Name of Medication / Strength (Dose) / How often taken? (3)
Name of Medication / Strength (Dose) / How often taken? (4)
Name of Medication / Strength (Dose) / How often taken? (5)
Name of Medication / Strength (Dose) / How often taken? (6)
Name of Medication / Strength (Dose) / How often taken? (7)
I Do Not Take Any Medications. (Please initial box)
Patient Signature
Date