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

Pre-Op/ Physical form

Please type in your 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?

YES

Home Glucose Readings:

High Blood Pressure: Any problems with meds?

YES

Home BP readings:

High Cholesterol: Any problem with meds?

YES

Depression: Any problem with meds?

YES

Any suicidal thoughts?

YES

Between Visits

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

YES

LifeStyle

Exercise: What do you do?

How long and How often?

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

YES

Smoking: How much do you smoke?

Are you interested in quitting?

YES

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

On average how many drinks per drinking day?

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

YES

Are you or others concerned about your drinking? *

YES

Falls : Have you fallen in the past year? *

YES

Do you have problems with walking or balance? *

YES

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

Yes

Do you regularly wear a seatbelt? *

YES

HIV Testing: Would you like HIV Testing? *

YES

( 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) *

Birth Control Method (if applicable)

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

YES

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? *

YES

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

YES

If so, What sort of problems are you having?

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

YES

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

YES

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? *

Any history of reactions to anesthesia? *

Any family history of malignant hyperthermia ?

elevated temperature with anesthesia. [new or family]

PHQ9

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

1. Little interest or pleasure in doing things *

2. Feeling down, depress or hopeless *

3. Trouble falling or staying asleep or sleeping too much *

4. Feeling tired or having little energy *

5. Poor appetite or overeating *

6. Feeling bad about yourself (that you are a failure, have let yourself or your family down) *

7. Trouble concentrating on things such as reading the newspaper or watching TV *

8. Moving or speaking so slowly that other people have noticed or the opposite, being fidgety or restless that you have been moving around a lot more than usual *

9. Thoughts that you would be better off dead or hurting yourself in some ways *

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? *

* Required field