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 (3) - HEALTH SCREENINGS

NEW PATIENT - HEALTH SCREENINGS

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 *

DATE OF BIRTH *

TODAY'S DATE *

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 or watching television *

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 of 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

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

Click SUBMIT FORM - Thank you for completing your forms in advance. We look forward to seeing you at your upcoming appointment!

* Required field