A Better Relationship Between Patient and Physician ...
BROADWAY SPORTS & INTERNAL MEDICINE, P.S.
1600 116TH AVE NE SUITE 202
BELLEVUE, WA 98004
P: 206 215-2288 F:206 215-2289
MEDICAL HISTORY QUESTIONNAIRE
Date__________ Name_____________________________ Date of Birth ___________ HT______ WT______
Current Medical Complaints
1._____________________________________
2._____________________________________
3._____________________________________
4._____________________________________
Current Medications
1._____________________________________
2._____________________________________
3._____________________________________
4._____________________________________
Medication Allergies/Sensitivities
1._____________________________________
2._____________________________________
3._____________________________________
Hospitalizations (please list on back if more)
1._____________________________________
2._____________________________________
5._____________________________________
Drugs Frequently or Presently Used:
__Sleeping Pills __Thyroid
__Tranquilizers __Heart Pill
__Anti-Depressant __Digitalis
__Diet Pills __Water Pill
__Estrogen Hormone __Blood Pressure Pill
__Birth Control Pill __Antacids
__Laxative __Vitamin D
__Decongestant __Vitamins
__Diabetic Pill __Antibiotics
__Asthma Pill __Insulin
__Nitroglycerin __”Recreational Drugs”
__Iron __Other
Medical Problems Previously Treated Surgeries/Accidents
1._____________________________________ 1.___________________________________
2._____________________________________ 2.___________________________________
3._____________________________________ 3.___________________________________
Date of Last Mammogram ____________________ Living Will Yes or No
Date of Last Colonoscopy ____________________
Date of Last Glaucoma Check ____________________
Social History:
Occupation_________________________ Marital Status: S M W D
Smoking: Alcohol Coffee
Packs Per Day________ Drinks Per Day_______ Cups Per Day ____________
Years Smoked________
Years Stopped________ Aspirin
Pipe_____ Cigar_____Chew_____ Tabs Per Day ____________
Vaccinations/Injections
__Tetanus _______Date __Hepatitis B _______Date
__Pneumonia _______Date __Flu _______Date
__Measles _______Date __Shingles _______Date
__Hormone _______Date __Other_________ _______Date
__Hepatitis A _______Date
FAMILY HISTORY
Please provide your FAMILY’s health history below by checking the boxes for mother and father, and specifying
other relatives (grandfather, for example) on the line provided. Family includes mother, father, brothers, sisters
and grandparents.
HAVE YOU ANY OF THE FOLLOWING IN THE LAST THREE MONTH
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HAVE YOU EVER EXPERIENCE ANY OF THE FOLLOWING:
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