Modupe Aiyegbusi, MD - Publicforms

Available Forms

Acute Visit Questionnaire Adult +18 CPE- Physical Forms Adult Health & History Form Adult Vaccine Questionnaire Ages 12-17 CPE - Physical forms Ages 5-8 CPE - Physical forms Ages 9-11 CPE Physical forms Child/Teen Vaccine Questionnaire Consent to use Telemedicine Covid-19 Screening Diabetes Form Flu Vaccine Questionnaire 21-22 Follow-Up Visit Questionnaire GAD 7- Generalized Anxiety Screening Medicare Wellness New Medicare Wellness New patient pediatric Health & History Form Ages 12-17 New patient pediatric Health & History Form Ages 5-8 New Patient Registration form all ages PHQ-9 - Patient Health Questionnaire Pre-Op/ Physical form Tuberculosis Risk Assesment Questionnaire

Adult +18 CPE- Physical Forms

Patient Name *

Date of Birth *

What are you hoping to accomplish today? *

Is there anything else you would like to work on to improve your health? *

If you have any of the following conditions, please answer:

Diabetes : Any problems with medications?

Home Glucose Readings:

Recent

High Blood Pressure: Any problems with meds?

Home BP readings:

Recent

High Cholesterol: Any problem with meds?

Depression: Any problem with meds?

Any suicidal thoughts?

Between Visits:

Have you been to the ER, Hospital or another doctor since last seen here? *

Life Style

Exercise: What do you do? *

How long and how often?

Can you walk a block or climb stairs without getting short of breath? *

Smoking: How much do you smoke? *

if no smoking put N/A

Are you interested in quitting?

Alcohol: How Many drinking days do you have per week? *

if no alcohol consumption put N/A

On average how many drinks per drinking day?

Have you had more than 4 drinks in a day in the past 3 months? *

Are you or others concerned about your drinking? *

Do you have problems with walking or balance? *

Falls : Have you fallen in the past year? *

Safety: Are you in a relationship where you feel unsafe or have been hurt? *

Do you regularly wear a seatbelt? *

HIV Testing: Would you like HIV Testing *

( If yes, please tell the nurse.) The HIV testing is recommended for anyone at risk for HIV infection, including persons with a sexually transmitted disease or history of injection drug use, sex workers, sexual partners of HIV-infected persons, or persons at risk.

Caffeine: How much caffeine do you consume per day? (e.g., coffee, tea, soda, chocolate) *

Sleep: Do you stop breathing during sleep or have concerns about sleep apnea? *

Birth Control Method (if applicable)

Depression Screen: Over the last 2 weeks have you been bothered by little interest or pleasure in doings things, or feeling down, hopeless or depressed? *

Medications: Do you have any trouble taking any of your meds? *

Medications: Do you have any trouble taking any of your meds?

Bladder Control: Do you lose control of your urine to the point you would like to know how to treat it? *

End-of-Life Care: Do you want to discuss end-of-life issues? *

UPDATES

Has anything new come up in your family history? *

( New Illness among blood relatives)

Have you developed any new drug allergies? *

Review of system

Are you experiencing any of the following? *

Any previous Surgeries? *

Staying Healthy Assessment Adult

Please answer all the questions on this form as best as you can. Select "skip" if you do not know an answer or no do not wish to answer. Be sure to talk to your doctor if you have any questions about anything on this form. Your answers will be protected as part of your medical record.

1. Do you drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt, soy milk or tofu? *

2. Do you eat fruits and vegetables every day? *

3. Do you limit the amount of fried food or fast food that you eat? *

4. Are you easily able to get enough healthy food? *

5. Do you drink a soda, juice drink, sports or energy drink most days of the week? *

6. Do you often eat too much or too little food? *

7. Are you concerned about your weight? *

8. Do you exercise or spend time doing activities, such as walking, gardening, swimming for 1/2 hour a day? *

9. Do you feel safe where you live? *

10. Have you had any car accidents lately? *

11. Have you been hit, slapped, kicked or physically hurt by someone in the last year? *

12. Do you always wear a seatbelt when driving or riding in a car? *

13. Do you keep a gun in your house or place where you live? *

14. Do you brush and floss your teeth daily? *

15. Do you often feel sad, hopeless, angry or worried? *

16. Do you often have trouble sleeping? *

17. Do you smoke or chew tobacco? *

18. Do friends or family members smoke in your house or place where you live? *

19. In the past year have you had : *

Alcohol

20. Do you use any drugs or medicines to help you sleep, relax, calm down, feel better or lose weight? *

21. Do you think your partner could be pregnant? *

22. Do you think you or your partner could have a sexually transmitted infection (STD), such as Chlamydia, Gonorrhea, Genital Warts, ect.? *

23. Have you or your partner(s) had sex without using birth control in the past year? *

24. Have you or your partner(s) had sex with other people in the past year? *

25. Have you or your partner(s) had sex without a condom in the past year? *

26. Have you ever been forced or pressured to have sex? *

27. Do you have any other questions or concerns about your health? *

If yes, please describe

PHQ-9 Screening - Depression

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little Interest or please in doings 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 or your family down? *

Trouble concentrating on things, such as reading the newspaper or watching television *

Moving or speaking slowly that other people could have noticed? Or the opposite-- being fidgety or restless that you have been moving around a lot more than usual *

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

Total Score *

If you checked off ANY problems, 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? *

GAD 7- Generalized Anxiety Screening

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious or on the edge? (choose one) *

2. Not being able to stop or control worrying? (choose one) *

3. Worrying too much about different things? (choose one) *

4. Trouble relaxing? (choose one) *

5. Being to restless that it's hard to sit still? (choose one) *

6. Becoming easily annoyed or irritable? (choose one) *

7. Feeling afraid as if something awful might happen? *

Total Score: *

If you checked off any problems, how difficult have these made it for you to do work, take care of things at home or get along with other people? (choose one) *

TB Screening Questionnaire

This Risk Assessment will be reviews by a licensed health care provider (physician, physician assistant, registered nurse or nurse practitioner)

LTBI testing is recommended if any of the boxes below are checked, no TB testing needed if checked None *

BIRTH, TRAVEL OR RESIDENCE for at least 1 month or frequent border crossing in a country with an elevated TB rate*

IMMUNOSUPPRESSION (Current or Planned) HIV infection, organ transplant recipient, treated with biological agents including TNF-alpha antagonist (e.g., infliximab, adalimumab, etanercept, others), steroids (equivalent of prednisone ?15mg/day for ?1 month) or other immunosuppressive medication.

CLOSE CONTACT to someone with infectious TB disease during lifetime

HOMELESSNESS OR INCARCERATION (current or past) Persons experiencing homelessness or residing in high-risk congregated settings including homelessness shelter or correctional facility during lifetime.

NONE; no TB testing is indicated at this time

Social DeterminantsOf Health Screening

Unmet social needs can negatively affect a person's health and wellbeing. There are programs available to help, but they aren't reaching everyone who may need them. Do you need help with any of these items?

Food

1. Within the past 12 months, did you worry that your food would run out before you got money to buy more? *

2. Within the past 12 months, did the food you bought just not last and you didn?t have money to get more? *

Housing & Utilities

3. Do you have housing? (Do you have somewhere to live?) *

4. Are you worried about losing your housing? *

5. Within the past 12 months. Have you or your family members you live with been unable to utilities (heat, electricity or water) when it was really needed? *

Transportation

6. Within the past 12 months, has lack of transportation kept you from medical appointments, getting your medicines, non-medical meetings or appointments, work or from getting things that you need? *

7. Do you have trouble finding or paying for transportation? *

Interpersonal Safety

8. Do you feel physically or emotionally safe where you currently live? *

9. Within the past 12 months, have you been hit, slapped, kicked or otherwise physically hurt by someone? *

10. Within the past 12 months, have you been humiliated or emotionally abused on other ways by your partner or ex-partner? *

Employment & Income

11. Do you have a steady source of income? *

Clothing & Household

12. Do you have enough household supplies? For example, clothing, bedding, hygiene products, infant products, or cleaning products? *

Childcare

13. Are you concerned that you won't have reliable childcare to go to work, school, or important appointments? *

Education

14. Do you think more education or training, like getting a GED, going to college, or learning a trade would be helpful for you? *

Resource Support

15. Are any of your needs urgent? For example, I don't have enough food for tonight, I don't have a place to sleep tonight, I'm afraid I will get hurt if I go home today. *

16. Would you like to receive assistance with any of these needs? *

E-HITS Domestic Violence Screening

Please read each of the following activities and select the option that best indicates the frequency with which your partner acts in the way depicted.

Over the last 12 months, how often did your partner:

1. Physically hurt you? *

2. Insult you or talk down to you? *

3. Threaten you with harm? *

4. Scream or curse at you? *

5. Force you to have sexual activities? *

Total Score: __________ (0-25)

Each item is scored from 1-5. Range is between 5-25. A score greater than 10 signify that you are at risk of domestic violence abuse, and should seek counseling or help from a domestic violence resource center such as the following: National Domestic Violence Hotline - 1.800.799.SAFE (7233) Women's and Children's Crisis Shelter - 562.945.3939 East LA Women's Center (ELAWC) - 800.585.6231 WomenShelter of Long Beach - 562.437.4663

AUDIT-C Questionnaire

1. How often do you have a drink containing alcohol? *

2. How many standard drinks containing alcohol do you have on a typical day? *

3. How often do you have six or more drinks on one occasion? *

* Required field