Progressive Medical Associates PLLC

This form is meant for New Patients, only. Patients with Medicare insurance (regardless of age) and patients with Medicare insurance who are 65+ years of age should complete this form. All other New Patient forms may be skipped, in lieu of this form, for those patients meeting the qualifications outlined above.

Registration Information

Patient Name * Birthdate * SSN * Sex * Gender Preferred Name Address * Preferred Phone * Secondary Phone Email Address * Marital Status * Race * Preferred Language Do you have any special communication needs, such as being hard of hearing, blindness, or trouble understanding? * Emergency Contact Person * Relationship to You * Emergency Contacts Phone & Address * Preferred Pharmacy * Mail Order Pharmacy (If Applicable) Primary Insurance Name * Name of Policy Holder * Member ID * Group Number * Birthdate of Policy Holder * Secondary Insurance (If Applicable) Will the patient be the financially responsible party? * If you answered "No" to the above question, who will be the financially responsible party? * Financially responsible party's relationship to you, phone, address and SSN

Signature

I confirm that I understand my insurance coverage is a relationship between my insurance company and myself and I agree to accept financial responsibility for charges incurred that are not reimbursed by my insurance company. I understand that I will be billed for "No Shows" or appointments not cancelled within 48 hours prior to my appointment time.

Electronic Signature * Date *

Medical & Family History

What is the reason for your visit today? * Please list any current or past medical concerns, along with the approximate year they occurred: * Please list any hospitalizations and the year they occurred, including surgeries * Please list any other physicians you are currently seeing, including the location and reason * Please list the medications you are taking, including over-the-counter, vitamins, herbs and birth control * Do you have any allergies to medications? * If you answered "yes" to the above question, please list any medications and your reaction to them Please check the box next to family members which are deceased * For relatives notated as deceased, please include any medical conditions and the age those conditions occurred * Have any family members suffered from high blood pressure, diabetes, high cholesterol, heart disease, prostate cancer, breast cancer, colon cancer, alcoholism, mental health concerns, or any other diagnosis you feel is important to your care?

Social History

What is/was your occupation? * Highest level of education? * Spouse's occupation? * Highest level of education? * Who lives at home with you? * Number of children & their ages? * Sexual Orientation? * Do you have any religious/spiritual beliefs we should know of and which pertain to your healthcare wishes? * Are you a current or former smoker? * If yes, how much do you smoke, daily? How many packs per day do/did you smoke? How many years have/did you smoke? If you quit, please notate what year If you do not currently smoke, have you ever been a cigarette, pipe, or cigar smoker? * Have you had any secondhand exposure to smoke, either currently or in the past? * Do you currently use recreational drugs? * Do you wear a seatbelt regularly? * Do you exercise regularly? * If you answered "yes" to the above question, what do you do for exercise and how often? What do you and your partner use for contraception? Would you like to be tested for STD's or HIV? *

Healthcare Wishes

Do you have a healthcare proxy or living will? * Are you willing to be an organ donor? * If you had a condition that had no chance of recovery, would you wish to remain on life support? * If you were unable to make your own healthcare decisions, whom would you like us to ask about what your wishes would be? * Is there an alternate person you would like listed, if you were unable to make medical decisions and we could not reach the first person?

Health Maintenance

Have you ever had any of the following items completed? * If you answered yes to any of the above, please list the approximate date Have you ever had any of the following items completed? * If you answered yes to any of the above, please list the approximate date FEMALE PATIENTS - Have you completed any of the following items? * If you answered yes to any of the above, please list the approximate date MALE PATIENTS - Have you completed the following item? * If you answered yes to any of the above, please list the approximate date

Social Determinants of Health

Have you been discharged from the Armed Forces of the United States? * Do you receive care from a VA clinic? * If you answered "yes" to the above question, please provide the name, address and phone number of the VA clinic you attend Do you need more assistance at home than you currently receive? * What is your living situation today? * In the past year, have you or any family members you live with been unable to get any of the following, when you really needed them? * In the past 2 months, did you or others you live with eat smaller meals or skip meals because you did not have money for food? * Do you feel confident using a computer, tablet, or phone for healthcare visits or finding information? * Has a lack of transportation kept you from medical appointments, meetings, work, or from getting items you need for daily living? * If you answered "yes" to the above question, please explain Do you feel physically and emotionally safe where you live? * To help determine if you may be eligible for government-sponsored financial assistance programs, we need to ask about your income. Are you ok with this? * Is your monthly income less than $1500.00 per month (or $2000.00 per married couple), including Social Security? * Are you interested in any of the following? *

Falls Risk Assessment

Have you fallen in the past year? * Do you use, or have you been advised to use, a cane or walker to get around safely? * Have you lost some feeling in your feet? * Do you feel unsteady while walking? *

Comprehensive Pain Assessment

Do you have pain currently? * What type of pain are you experiencing? Where is your pain located? Please describe your pain On a scale of 1-10, please rate your pain What makes your pain better? What makes your pain worse? How would you describe how much your pain has been relieved in the past week? Is the amount of relief you are receiving enough to make a real difference in your life? Are you meeting your pain goals?

Annual Health Screenings

Over the past 2 weeks, how often have you been bothered by any of the following items? Please check the appropriate boxes

Little interest or pleasure in doing things * Feeling down, depressed, or hopeless * Trouble falling or staying asleep, or sleeping too much * Feeling tired or having little energy * Poor appetite or overeating * Feeling bad about yourself, or that you are a failure or have let yourself/your family down * Trouble concentrating on things, such as reading the newspaper or watching television * Moving or speaking so slowly that others may have noticed, or being so fidgety or restless that you've been moving around more than normal * Thoughts that you would be better off dead or of hurting yourself in some way * How difficult have these problems made it for you to do your work, take care of things at home, or get along with others? * How often do you have a drink containing alcohol? * How many standard drinks containing alcohol do you have on a typical day, when you drink? * How often do you have 6+ drinks on a single occasion? *

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