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Available Forms

NEW PATIENT REGISTRATION

DEMOGRAPHICS

Enter "NONE" if you do not use Email
 

HEALTH INSURANCE

If NO, skip to the Financially Responsible Party section. If YES, please answer the following questions regarding your primary health insurance plan.
 
 
 
 
 
Primary Insurance
Primary Insurance
 
If No, Skip to Financially Responsible Party Section. If YES, please answer the following questions regarding your secondary health insurance plan.
 
 
 
 
 
Secondary Insurance
Secondary Insurance
 

Financially Responsible Party

Name of the person responsible for paying medical bills
 
 

If the person who is financially responsible is someone other than the patient, please answer the following regarding the responsible party:

By my signature below, I confirm that I understand that 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 may be billed for "No Shows" or appointments not cancelled within 48 hrs prior to the appointment time. If I am signing as the financially responsible party on behalf of the patient, I understand that my financial responsibility will remain in force until I notify the practice in writing that I am no longer financially responsible.

If patient is under the age of 18, must be signed by financially responsible party.
mm/dd/yyyy
 

NEW PATIENT HEALTH QUESTIONNAIRE

Select all that apply.
 
Please list any current or past medical problems, along with the approximate year they occurred (or indicate "NONE").
 
Please list any hospitalizations and the approximate year they occurred, including surgeries (or indicate "NONE").
 
Please list any other physicians you are currently seeing and the reason that you see them (or indicate "NONE")
 

MEDICATIONS

List all medications you are taking (including over-the-counter, vitamins, herbs & birth control). List the MEDICATION, the DOSAGE, and HOW OFTEN YOU TAKE IT. (Or indicate "NONE" if you don't take any medications)
 
 

FAMILY HISTORY

PLEASE ANSWER THE FOLLOWING REGARDING THE MEDICAL HISTORY OF YOUR BIOLOGICAL FAMILY.

Father

Check all that apply.
If your father has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
 

Mother

Check all that apply.
If your mother has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
 

Siblings

Indicate whether your siblings are living or deceased. If any are deceased, list approximate age at death. If you have no siblings, enter NONE.
Check all that apply.
If any of your siblings have a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
 

Grandmother (Mother's Side)

Check all that apply.
If your maternal grandmother has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
 

Grandfather (Mother's Side)

Check all that apply
If your maternal grandfather has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
 

Grandmother (Father's Side)

Check all that apply.
If your paternal grandmother has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
 

Grandfather (Father's Side)

Check all that apply.
If your paternal grandfather has a history positive for any type of cancer, please list the type of cancer and the approximate age at diagnosis. Also, please list any other significant medical issues not indicated above.
 

Other Family Members

Are there any other family members who have suffered from diabetes, high blood pressure, heart disease, cancer, or any other conditions you feel are important? FOR ANY HISTORIES OF CANCER, please indicate type of cancer and approximate age at diagnosis
 

HEALTH MAINTENANCE

Please indicate the approximate date (year) of the last time you had the following medical services. If you have never had them or it doesn't apply to you, enter NONE or N/A. If you are unsure if you have ever had it, enter UNSURE.

 

SOCIAL HISTORY

 
 
 
 
 

HEALTHCARE WISHES

 
If I had a readily reversible condition like a bad pneumonia, I would want to be placed on life support temporarily; however, I would not wish to remain on life support if I had no chance for a quality of life.
 

If you were unable to make your own healthcare decisions (for instance, you were in a coma from a car accident), whom would you want us to ask about what your wishes would be? Please name one person and one alternate. You can also fill out a healthcare proxy form.

 

Annual Health Screening - PHQ-9

OVER THE LAST 2 WEEKS, how often have you been bothered by any of the following problems?

 
 
 
 
 
 
 
 
 
 

Annual Health Screening - AUDIT C

 
 
 

AUTHORIZATION FOR RELEASE OF INFORMATION TO FAMILY AND/OR FRIENDS

Spouse / Partner

Do you authorize the release of protected health information to your spouse/partner? IF YES, provide the name of your spouse/partner and the nature of information that you authorize them to receive. IF NO, skip to FAMILY/FRIENDS.

Check all types of information that you authorize your spouse / partner to receive.
 

Family / Friends

Do you authorize the release of protected health information to any family or friends? IF YES, provide the name(s) of authorized family or friends, their relationship to you, and the nature of the information that you authorize them to receive. IF NO, skip to SIGNATURE.

NAME - RELATIONSHIP TO YOU - Indicate "MEDICAL", "FINANCIAL", or "ALL"
 

Signature

I understand that I have the right to revoke this authorization at any time by sending a written notification to Progressive Medical Associates. I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective immediately upon receipt of written notification by this practice. I understand that information disclosed as a result of this authorization may be subject to re-disclosure by the recipient and no longer protected by federal or state law. This authorization shall remain in force and effect until revoked by the patient or patient's representative.

If signed by someone other than the patient.
 
Please check the boxes to acknowledge that you received these documents by email.
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