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

**NEW PATIENT (2) - HEALTH QUESTIONNAIRE

NEW PATIENT HEALTH QUESTIONNAIRE

NEW PATIENTS ONLY. Please make sure you fill out all THREE (3) forms labeled "New Patient" (see list on the left). Submit all 3 forms: NEW PATIENT (1) REGISTRATION; NEW PATIENT (2) HEALTH QUESTIONNAIRE; and NEW PATIENT (3) ANNUAL HEALTH SCREENINGS. If you are a new patient with Medicare insurance, please also complete form (4) NEW PATIENT - MEDICARE

FIRST & LAST NAME *

What is the reason for your visit? *

Become established with the practice

Physical / Wellness Exam

Sick

Select all that apply.

Current or Past Medical Problems *

Please list any current or past medical problems, along with the approximate year they occurred (or indicate "NONE").

Hospitalizations / Surgeries *

Please list any hospitalizations and the approximate year they occurred, including surgeries (or indicate "NONE").

Your Other Physicians *

Please list any other physicians you are currently seeing and the reason that you see them (or indicate "NONE"). For example, an endocrinologist that you see for diabetes.

MEDICATIONS

Current Medication List *

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)

Do you have any allergies or intolerances to any medications? *

Yes

If Yes, please list the medications and reaction that you have to each medication

FAMILY HISTORY

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

Father

Father *

Living

Deceased

Unknown

If deceased, approximate age of death

Medical History of Father *

Check all that apply.

Father:

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

Mother *

Living

Deceased

Unknown

If deceased, approximate age of death

Medical History of Mother: *

Check all that apply.

Mother:

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

Do you have any siblings? If none, please select "no". If yes, please indicate how many. *

Please indicate your siblings names, genders and ages.

How many of your siblings are living? *

Please indicate how many of your siblings are living.

How many of your siblings are deceased? *

Please indicate how many of your siblings are deceased.

Please indicate what ages your siblings passed, as well as their cause of death, if known.

Medical History of Siblings *

Check all that apply.

Siblings:

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)

Grandmother (Mother's side) *

Living

Deceased

Unknown

If deceased, approximate age of death

Medical Issues of Grandmother (Mother's Side): *

Check all that apply.

Grandmother (Mother's Side):

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)

Grandfather (Mother's side) *

Living

Deceased

Unknown

If deceased, approximate age of death.

Medical History of Grandfather (Mother's Side): *

Check all that apply

Grandfather (Mother's Side):

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)

Paternal Grandmother (Father's side) *

Living

Deceased

Unknown

If deceased, list approximate age of death.

Medical History of Grandmother (Father's Side): *

Check all that apply.

Grandmother (Father's Side):

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)

Grandfather (Father's side) *

Living

Deceased

Unknown

If deceased, list approximate age of death.

Medical History of Grandfather (Father's Side): *

Check all that apply.

Grandfather (Father's Side)

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

Medical history of other family members (aunts, uncles, children, etc.)

Are there any other family members who have suffered from diabetes, high blood pressure, high cholesterol, 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.

Physical Exam *

Cholesterol Checked *

Colonoscopy or Sigmoidoscopy or Cologuard *

Flu Shot *

Covid-19 Vaccine *

Pneumonia Shot *

Tetanus Shot *

Shingles Shot *

Hepatitis Shot *

Skin Test for TB (PPD) *

HIV Screening *

Hepatitis C Screening *

Physician Breast Exam (FEMALES)

PAP Smear (FEMALES)

Mammogram (FEMALES)

Bone Density (FEMALES)

PSA Blood Test (MALES)

Eye Exam *

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

Yes

SOCIAL HISTORY

Your Occupation *

Highest Level of Education/Degree *

Spouse's Occupation (if applicable):

Spouse's highest level of education (if applicable):

Number of Children (and their ages)

Who lives at home with you? *

Sexual Orientation *

Heterosexual

Homosexual

Bisexual

Other

Religion

Do you currently smoke? *

Yes

If Yes, how much do you smoke daily?

If you do NOT currently smoke, have you EVER been a cigarette, pipe, or cigar smoker? *

Yes

If you quit, how many packs per day did you smoke previously?

How many years did you smoke?

Approximate year that you quit

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

Yes

Do you currently use recreational drugs like marijuana or cocaine? *

Yes

Do you wear a seatbelt regularly? *

Yes

Do you exercise regularly? *

Yes

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

Please describe your typical diet. *

What do you & your partner use for contraception (if applicable)?

Do you have any concerns about, or would you like to be tested for STDs or HIV? *

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

Unsure

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.

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

ALTERNATE: Name, Phone Number, and Relationship to You

Preferred Local Pharmacy and the location of the pharmacy *

Mail Order Pharmacy (if you have one):

Click SUBMIT FORM and then complete the last form called "NEW PATIENT (3) - HEALTH SCREENINGS"

* Required field