Progressive Medical Associates PLLC

Available Forms

**NEW PATIENT (1) - REGISTRATION FORM **NEW PATIENT (2) - HEALTH QUESTIONNAIRE **NEW PATIENT (3) - HEALTH SCREENINGS **NEW PATIENT - MEDICARE (Age 65 + ) *ANNUAL WELLNESS (Age 65 + ) *ANNUAL WELLNESS (Under Age 65) CONTACT FORM FORGOT MY USERNAME MAKE A CO-PAYMENT ON YOUR ACCOUNT MAKE A PAYMENT ON YOUR ACCOUNT MAKE PAYMENT ARRANGEMENTS UPDATE DEMOGRAPHICS UPDATE EMAIL ADDRESS UPDATE INSURANCE INFORMATION VITALS & CO-PAY

*ANNUAL WELLNESS (Age 65 + )

ANNUAL WELLNESS (Age 65+) -- (For Established Patients Only - Do Not Submit this form if you are a NEW Patient)

Do NOT submit this form unless you are an ESTABLISHED PATIENT who has an upcoming appointment for an Annual Wellness Exam (Physical) AND you are AGE 65 or over. NOTE: NEW Patients should NOT use this form and should only submit the forms labeled "NEW PATIENT"

FIRST NAME *

LAST NAME *

DATE OF BIRTH *

Patient Sex Assigned At Birth *

Gender

How do you choose to identify and what are your choice pronouns, if any?

Current Mailing Address *

Current Email Address: *

Has anything changed in regard to your health in the past year? *

Yes

(such as new illnesses, surgeries, new medication allergies or intolerances, etc)

If you answered yes to the above question, please list what changes you have experienced.

(such as increased stress, new job, home, relationship, children, ill relatives, etc)

Have any blood relatives developed any new illnesses in the last year? *

Yes

(If any blood relative has had cancer, please list their relation to you, the type of cancer & how old they were when diagnosed)

If you answered yes to the above question, please list what relatives and conditions they developed.

(If any blood relative has had cancer, please list their relation to you, the type of cancer & how old they were when diagnosed)

If you have had any vaccines in the past year, please list with the approximate date:

What is (or was) your occupation? If retired, what year did you retire? *

If you have children, what are their names and ages?

If you CURRENTLY use tobacco, what kind do you use? *

Cigarettes

Cigars

Pipe

Vape

Chew

I do not currently use tobacco

(Check all that apply)

If you currently use tobacco, how much do you smoke (use) daily?

If you are a FORMER user of tobacco, what kind did you use?

Cigarettes

Cigars

Pipe

Vape

Chew

(Check all that apply)

If you are a former smoker, please answer the following questions related to your smoking history:

Approximately, how many packs per day did you smoke?

How many years did you smoke?

Approximately what year did you quit?

Have you had any exposure to secondhand smoke (others smoking around you) currently or in the past? *

Yes

If yes, please explain your exposure:

Do you currently use recreational drugs (like marijuana, etc)? *

Yes

Do you wear a seat belt? *

Yes

Do you get regular exercise? *

Yes

If yes, what do you do for exercise and how often?

Please describe your diet: *

Have you had a new sexual partner in the past year? *

Yes

Would you like to be tested for HIV or other STDs? *

Yes

Not Applicable

Do you have any difficulties with hearing that limits your personal life? *

Yes

Do you see a dentist at least once a year? *

Yes

During the past 4 weeks, how would you rate your health? *

Excellent

Very Good

Good

Fair

Poor

Do you have any difficulties driving your own car or getting transportation if you do not drive? *

Yes

During the past 4 weeks, was someone available to help you if you needed and wanted help? *

Yes

Have you fallen 2 or more times in the past year? *

Yes

Are you concerned about falling? *

Yes

ARE YOU ABLE TO HANDLE THE FOLLOWING ACTIVITIES WITHOUT HELP?

Shopping for groceries or clothes? *

Yes

Doing housework? *

Yes

Keeping track of medications? *

Yes

Preparing your own meals? *

Yes

Handling your own money? *

Yes

Bathing or dressing? *

Yes

HEALTHCARE WISHES

Do you have a healthcare proxy or living will? *

Yes

Not Sure

Are you willing to be an organ donor? *

Yes

Not Sure

Most healthy patients would like to be treated aggressively (such as CPR, respirator, ICU, etc) if they had a potentially curable condition.

If you had a condition that had no chance of recovery, would you wish to remain on life support? *

Yes

Not Sure

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 to be asked about what your healthcare wishes would be? Name one primary person and one alternate.

PRIMARY: Name, Phone Number, and Relationship to You *

ALTERNATE: Name, Phone Number, and Relationship to You

Please list any other physicians you are currently seeing and the reason you see them:

(For example, an endocrinologist that you see for diabetes)

Annual Health Screening - PHQ-9

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

Little interest or pleasure in doing things *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Feeling down, depressed, or hopeless *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Trouble falling or staying asleep, or sleeping too much *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Feeling tired or having little energy *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Poor appetite or overeating *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Feeling bad about yourself - or that you are a failure or have let yourself or your family down *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Trouble concentrating on things, such as reading *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Moving or speaking so slowly that others could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

If you checked off ANY of the problems listed above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

0 - Not difficult at all

1 - Somewhat difficult

2 - Very difficult

3 - Extremely difficult

Annual Health Screening - AUDIT C

How often do you have a drink containing alcohol? *

0 - Never

1 - Monthly or Less

2 - Two to Four times a Month

3 - Two to Three times a Week

4 - Four or More times a Week

How many standard drinks containing alcohol do you have on a typical day when you drink? *

0 - Do not drink any alcohol

0 - One or Two

1 - Three or Four

2 - Five or Six

3 - Seven to Nine

4 - Ten or More

How often do you have 6 or more drinks on one occasion? *

0 - Never

1 - Less than Monthly

2 - Monthly

3 - Weekly

4 - Daily or Almost Daily

Social Determinants of Health

Have you been discharged from the Armed Forces of the United States? *

Yes

Do you receive care from a VA clinic? *

Yes

What is the name and address of the VA clinic you attend?

Do you need more assistance than you currently receive? *

Yes

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? Choose all that apply. *

Food/Groceries

Housing

Medications

Money

Transportation

Healthcare/Treatment

Other

In the past 2 months, did you or others you live with eat smaller meals or skip meals because you did not have enough money for food? *

Yes

Are you confident using a computer, tablet, or phone for healthcare visits or finding information? *

Yes

Has a lack of transportation kept you from medical appointments, meetings, work, or from getting items you need for daily living? If yes, please explain. *

Do you feel physically and emotionally safe where you currently live? *

Yes

To help determine if you may be eligible for government-sponsored financial assistance programs, please notate if your monthly income is less than $1500.00 per month (or $2000.00 per married couple), including Social Security?

Yes

Have you fallen in the past year? *

Yes

Do you use of have you been advised to use a cane or walker to get around safely? *

Yes

Have you lost some feeling in your feet? *

Yes

Do you feel unsteady when walking? *

Yes

Do you have either Acute Pain (comes on quickly, can be severe, lasts a relatively short period of time) or Chronic Pain (pain which goes beyond the expected healing time, usually lasting greater than 6 months)? *

Acute Pain

Chronic Pain

No Pain

Where is your pain located? On a scale of 1-10, with 1 being the least and 10 being the most, what level is your pain usually at? Currently at? *

What makes your pain better? *

What makes your pain worse? *

How would you describe how much your pain has been relieved within the past week?

Is the amount of relief you are receiving high enough to make a real difference in your life? *

Yes

Are you meeting your pain goals? *

Yes

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