Progressive Medical Associates PLLC

To help ensure a smooth and efficient visit, please provide your blood pressure, height, weight, temperature, smoking status, allergies and preferred pharmacy.   A Medical Assistant will call you, prior to your appointment, to review your medications.

Patient Name (Last, First): * Patient Date of Birth: *

Please provide your vital signs in the spaces below.

Date of Appointment: * Blood Pressure: * Height: * Temperature: * Weight: * Pulse: Oxygen Saturation:

Please answer the following questions pertaining to smoking history.

Have you ever been a smoker? * If you are a current or former smoker, how many packs per day do/did you use? If you are a current or former smoker, at what age did you begin smoking? If you are a former smoker, at what age did you quit?

Please answer the following questions pertaining to known allergies.

Do you have any known allergies? * If you answered "Yes" to the above question, please list your known allergies and reactions.

Please select your pharmacy, below.

Local Pharmacies * Please provide the address and phone number for your pharmacy. Mail Order Pharmacies *

Thank you for completing this form and helping us prepare for your visit. A Medical Assistant will contact you shortly, to review your medications.