Progressive Medical Associates PLLC

This form is meant for New Patients, only. Patients with any insurance except Medicare and patients under 65 years of age should complete this form.

Registration Information

Patient Name * Birthdate * SSN * Sex * Gender Preferred Name Address * Preferred Phone * Secondary Phone Email Address * Marital Status * Race * Preferred Language Do you have any special communication needs, such as being hard of hearing, blindness, or trouble understanding? * Emergency Contact Person * Relationship to You * Emergency Contacts Phone & Address * Preferred Pharmacy * Mail Order Pharmacy (If Applicable) Primary Insurance Name * Name of Policy Holder * Member ID * Group Number * Birthdate of Policy Holder * Secondary Insurance (If Applicable) Will the patient be the financially responsible party? * If you answered "No" to the above question, who will be the financially responsible party? Financially responsible party's relationship to you, phone, address and SSN

Signature

I confirm that I understand 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 will be billed for "No Shows" or appointments not cancelled within 48 hours prior to my appointment time.

Electronic Signature * Date *

Medical & Family History

What is the reason for your visit today? * Please list any current or past medical concerns, along with the approximate year they occurred: * Please list any hospitalizations and the year they occurred, including surgeries * Please list any other physicians you are currently seeing, including the location and reason * Please list the medications you are taking, including over-the-counter, vitamins, herbs and birth control * Do you have any allergies to medications? * If you answered "yes" to the above question, please list any medications and your reaction to them Please check the box next to family members which are deceased * For relatives notated as deceased, please include any medical conditions and the age those conditions occurred * Have any family members suffered from high blood pressure, diabetes, high cholesterol, heart disease, prostate cancer, breast cancer, colon cancer, alcoholism, mental health concerns, or any other diagnosis you feel is important to your care?

Social History

What is/was your occupation? * Highest level of education? * Spouse's occupation? * Highest level of education? * Who lives at home with you? * Number of children & their ages? * Sexual Orientation? * Do you have any religious/spiritual beliefs we should know of and which pertain to your healthcare wishes? * Are you a current or former smoker? * If yes, how much do you smoke, daily? How many packs per day do/did you smoke? How many years have/did you smoke? If you quit, please notate what year If you do not currently smoke, have you ever been a cigarette, pipe, or cigar smoker? * Have you had any secondhand exposure to smoke, either currently or in the past? * Do you currently use recreational drugs? * Do you wear a seatbelt regularly? * Do you exercise regularly? * If you answered "yes" to the above question, what do you do for exercise and how often? Please describe your diet * What do you and your partner use for contraception? Would you like to be tested for STD's or HIV? *

Healthcare Wishes

Do you have a healthcare proxy or living will? * Are you willing to be an organ donor? * If you had a condition that had no chance of recovery, would you wish to remain on life support? * If you were unable to make your own healthcare decisions, whom would you like us to ask about what your wishes would be? * Is there an alternate person you would like listed, if you were unable to make medical decisions and we could not reach the first person?

Health Maintenance

Have you ever had any of the following items completed? * If you answered yes to any of the above, please list the approximate date Have you ever had any of the following items completed? * If you answered yes to any of the above, please list the approximate date FEMALE PATIENTS - Have you completed any of the following items? * If you answered yes to any of the above, please list the approximate date MALE PATIENTS - Have you completed the following item? * If you answered yes to any of the above, please list the approximate date

Annual Health Screenings

Over the past 2 weeks, how often have you been bothered by any of the following items? Please check the appropriate boxes

Little interest or pleasure in doing things * Feeling down, depressed, or hopeless * Trouble falling or staying asleep, or sleeping too much * Feeling tired or having little energy * Poor appetite or overeating * Feeling bad about yourself, or that you are a failure or have let yourself/your family down * Trouble concentrating on things, such as reading the newspaper or watching television * Moving or speaking so slowly that others may have noticed, or being so fidgety or restless that you've been moving around more than normal * Thoughts that you would be better off dead or of hurting yourself in some way * How difficult have these problems made it for you to do your work, take care of things at home, or get along with others? * How often do you have a drink containing alcohol? * How many standard drinks containing alcohol do you have on a typical day, when you drink? * How often do you have 6+ drinks on a single occasion? *

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