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

New Medicare Wellness

Patient Name *

Date of Birth *

Marital Status *

Do you have an Advanced Directive? *

What is the reason for your visit today? *

Which Pharmacy do you use? *

Please provide pharmacy name, address and phone number.

For your Annual Medicare Wellness Visit

Tobacco, Alcohol and Drug Use

Cigarettes (Choose one) *

Never

Current Smoker

Former Smoker

Other Tobacco:

Pipe

Snuff

Cigar

Chew

Vape

Are you interested in quitting/ (Choose one)

YES

Alcohol Use (Choose one)

Yes

How many alcoholic drinks a week?

Have you used recreational drugs? (Choose one)

Yes

If so, Which recreational drugs have you used?

Have you ever used needles to inject drugs? (Choose one)

Yes

Drink Caffeine (Choose one)

Yes

How many cups of caffeine per day?

Hospitalizations:

any recent hospitalization

If yes, please provide name or hospital and Date of your visit.

Specialist List:

any specialist you are seeing

please provide doctors name and specialty

Medication List:

Medications: Prescriptions and non-Prescription medications, vitamins, home remedies, birth control pills and herbs

Please tell us the name of the medication, strength and how many times you take it per day.

Major Surgeries

Abdominal

Appendix

Breast

Gallbladder

Heart

Orthopedic

Uterus/Ovary

Any other Surgeries

Sexual Activity

Sexual Activity (choose one)

YES

NOT CURRENTLY

Current Sex Partner(s)

Female

Male

Are you interested in having STD Screening? (Choose one)

Yes

Children (Choose one)

None

Staying Healthy Assessment

Please answer all the questions on this form as best as you can. Click/circle "Skip" if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have 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 soda, juice drink, sports or energy drinks most days of the week? *

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

7. Do you have difficulty chewing or swallowing? *

8. Are you concerned about your weight? *

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

10. Do you feel safe where you live? *

11. Do you often have trouble keeping track of your medicines? *

12. Are family members or friends worried about your driving? *

13. Have you had any car accidents lately? *

14. Do you sometimes fall and hurt yourself or is it hard to get up? *

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

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

17. Do you brush or floss your teeth daily? *

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

19. Do you often have trouble sleeping? *

20. Do you or others think that you are having trouble remembering things? *

21. Do you smoke or chew tobacco? *

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

23. In the past year, have you had 4 or more alcohol drinks in one day? *

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

25. Do you think you or your partner could have a sexually transmitted infection (STI), such as Chlamydia, Gonorrhea, genital warts, etc.? *

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

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

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

29. Do you have someone to help you make decisions about your health and medical care? *

30. Do you need help bathing, eating, walking, dressing or using the bathroom? *

31. Do you have someone to call when you need help in an emergency? *

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

If yes, please describe:

Activities of Daily Living (ADL)

Using Telephone *

I= Able to look up numbers, dial, receive and make calls without help

A= Able to answer phone or dial operator in an emergency but needs special phone or help in getting number, dialing

D= Unable to use phone

Traveling *

I= Able to drive own car or travel alone on bus or taxi

A= Able to travel but needs someone to travel with

D= Unable to travel

Shopping *

I= Able to take care of all food/clothes shopping

A= Able to shop but needs someone to shop with

D= Unable to shop

Preparing Meals *

I= Able to plan and cook meals

A= Able to prepare light foods but unable to cook full meals alone

D= Unable to cook

Housework *

I= Able to do heavy housework. (i.e. Scrub floors)

A= Able to do light housework, but needs help with heavy tasks

D= Unable to do any housework

Taking Medicines *

I= Able to prepare/take medications in the right dose at the right time

A= Able to take medication, but needs reminding or someone to prepare them

D= Unable to take medications

Managing Money *

I= Able to manage buying needs. (i.e. Write checks, pay bills)

A= Able to manage daily buying needs but needs help managing checkbook, paying bills

D= Unable to manage money

Hearing

Do you have a hearing problem? *

Safety & Fall Risk Assessment

1. Have you fallen in the past 6 months? *

2. If you answered Yes to question #1, were you injured?

3. Have you experienced urgency or frequency with elimination in the past 6 months *

4. Have you expirienced episodes of dizziness in the past 6 months? *

5. Do you use any assitive devices for ambulation? *

5a. If you answered YES, Please check off the device used

Another Person

Railing

Cane

Walker

Wheelchair

6. Do you feel you could benefit from installing grab bars on your tub and/or shower? *

7. Does your home lack smoke detectors or sprinklers? *

8. Do you sometimes forget to fasten your seat belt when traveling in a car? *

9. Does your home have a fireplace? *

10. Do you smoke? *

11. Do you drink alcohol at least twice a week? *

12. Do you use oxygen on a regular basis? *

13. Does your home lack a fire extinguisher? *

14. Do you use scatter rugs throughout your home? *

15. Does your home have a pool or hot tub? *

PHQ9

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

Little Interest or Pleasure in doing things? *

Feeling down, depressed or hopeless *

Trouble falling/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 so fidgety or restless that you have been moving around more than usual *

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

If you checked off ANY problem on this questionnaire so far, How difficult have these problems made it for you to do your work, take care at home or get along with other people? *

Total Score *

PAIN SURVEY

Many people have pain, but do not discuss with their doctors. We encourage you to fill out the the questionnaire below. Your answers will be sent to the doctor so that you can discuss these problems at your visit.

Gender *

Male

Female

Age *

In the last week, on average, How would you rate your pain? *

use scale 0-10, where 0 is "no pain" and 10 is "pain as bad as could be" ( That is, Your usual pain when you were in pain.")

In the last month, How much has pain interfered with your daily activities? *

Use scale from 0-10, where 0 is "No interference" and 10 is "unable to carry on any activities"

How long have you had the pain? *

in days, weeks, months or year

I currently: *

Am not working

Work Part-Time

Work Full-Time

How many days in the past month have you been bothered by pain with doing daily activities? *

How many days in the past month have you missed doing daily activities due to pain? *

Overall , How satisfied are you with your current pain medications? *

Overall, How does your level of pain relief meet your expectations of pain relief? *

Over Active Bladder ( Urinary Incontinence or Frequent Urination) Awareness Tool

Many people are bothered by bladder symptoms, but may be reluctant to discuss these problems with their doctors. We encourage you to fill out the questionnaire below.

During the past 4 weeks, how bothered were you by:

Frequent urination during the daytime hours *

An uncomfortable urge to urinate *

A sudden urge to urinate with little or no warning *

Accidental loss of small amounts of urine *

Night time urination *

Waking up at night because you had to urinate *

An uncontrollable urge to urinate *

Urine loss associated with a strong desire to urinate *

Do you currently take any medication for bladder symptoms? *

How many times do you get up at night to use the bathroom? *

GAD7- Generalized Anxiety Screening

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

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

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) *

Other Concerns

Weight: Is your weight a concern? (Choose one)

Yes

Diet: How do you rate your diet? (Choose one)

Good

Fair

Poor

Exercise: Do you exercise regularly? (Choose one)

Yes

What Kind of exercise? How long? and How often?

Past Exam and Test

Bone Density

Approximately when?

Colonoscopy

Approximately when?

Mammogram

Approximately when?

Pap Smear

Approximately when?

PSA Test

Approximately when?

Treadmill (Heart)

Approximately when?

Allergies or Reactions to Medicines/Food/Other Agents:

Please tell us what causes allergies or reactions to you and what side effects it causes

Family History

Alcohol Abuse

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

Diabetes

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

Breast Cancer

Mother

Maternal Grandmother

Paternal Grandmother

Sister(s)

Others

Colon Cancer

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

Heart Disease

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

High Cholesterol

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

High Blood Pressure

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

Prostate cancer

Father

Maternal Grandfather

Brother(s)

Others

Lung Cancer

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

Mental Health Disorder

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Maternal Grandfather

Brother(s)

Sister(s)

Others

Adult Immunization

Gardasil

if yes, when?

Hepatitis B

if yes, when?

Influenza (Yearly)

if yes, when?

Pertussis

if yes, when?

Pneumonia

if yes, when?

Shingles

if yes, when?

Tetanus

if yes, when?

Social Determinants Of Health Screening

Food

1. Within the past 12 months, did you worry that your food 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? *

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 get utilities (heat, electricity) 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 and 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 in 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

* Required field