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 Health & History Form

PATIENT HISTORY FORM- ADULT

Name: *

Date Of Birth *

Main reason for visit today: *

Symptoms : Check the symptoms you CURRENTLY have in the PAST 2 WEEKS

General

Muscle/Joint/Bone- Pain , weakness , numbness, ect

Arms

Back

Feet

Hands

Hips

Legs

Neck

Shoulders

Genito-Urinary

Blood in urine

Frequent Urination

Lack of Bladder Control

Painful Urination

Gastrointestinal

Cardiovascular

Chest Pain

High Blood Pressure

Irregular Heart Beat

Low Blood Pressure

Poor Circulation

Rapid Heart Rate

Swelling of Ankles

Varicose Veins

Eye, Ear, Nose, Throat

Skin

Bruise Easily

Hives

Itching

Changes in Moles

Rash

Scars

Sores that won't heal

Medical History

Major Surgeries

Abdominal

Appendix

Breast

Gallbladder

Heart

Orthopedic

Uterus/Ovary

Any other Surgeries

Sexual Activity

Sexually Active

YES

NOT CURRENTLY

Current Sex Partner(s)

Female

Male

Are you interested in having STD Screening? *

Yes

Children *

None

Occupation:

Drink Caffeine

Yes

How Many cups of caffeine per day?

Alcohol Use

Yes

How many alcoholic Drinks per Week?

Have you used recreational drugs? *

Yes

If so, Which recreational drugs have you used?

Have you ever used needles to inject drugs?

Yes

Tobacco Use:

Cigarettes

Never

Current Smoker

Quit Smoking

Other Tobacco:

Pipe

Snuff

Cigar

Chew

Vape

Are you interested in quitting?

Yes

Other Concerns

Weight: Is your weight a concern? *

Yes

Diet: How do you rate your diet? *

Good

Fair

Poor

Exercise: Do you exercise regularly? *

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?

Treamill (heart)

Approximately when?

Have you completed a living will or durable power of attorney for health care? *

Yes

Medications: Prescriptions and Non-Prescriptions medicines, vitamins, home remedies, birth control pills and herbs

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

Allergies or Reactions to Medicines / Food / Other Agents:

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

Family History

Alcohol Abuse

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Brother(s)

Sister(s)

Others

Diabetes

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal 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

Paternal Grandfather

Brother(s)

Sister(s)

Others

Heart Disease

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Brother(s)

Sister(s)

Others

High Cholesterol

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Brother(s)

Sister(s)

Others

High Blood Pressure

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Brother(s)

Sister(s)

Others

Prostate Cancer

Father

Maternal Grandfather

Paternal Grandfather

Brother(s)

Others

Lung Cancer

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Brother(s)

Sister(s)

Others

Mental Health Disorder

Father

Mother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Brother(s)

Sister(s)

Others

Adult Immunizations

Gardasil

If yes, when ?

Hepatitis B

If yes, when?

Influenza ( Yearly)

If yes, when?

Pertussis

If yes, when? (Tdap)

Pneumonia

If yes, when and which one?

Shingles

If yes, when and which one?

Tetanus

If yes, when?

Women

Date of Last Menstrual period:

Do you take any of the following?

Calcium

Vitamin D

Hormone Replacement Therapy

Do you have any of the following symptoms?

Bleeding between periods

Breast lump

Extreme menstrual pain

Hot Flashes

Nipple Discharge

Painful Intercourse

Vaginal Discharge

Other

Men

Do you have any of the following problems?

Waking up at night to urinate

Difficulty starting urine stream

Lump in Testicle/s

Penis Discharge

Sore on Penis

Sexual Concerns (getting or keeping an erection

Have you had an abnormal PSA

Other

Staying Healthy Assesment 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 litle 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 : *

Men: 5 or more alcohol drinks in one day?

Women: 4 or more drinks in one day?

Yes

Skip

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 partnet(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

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 televison *

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 *

add the numbers at the end of your response

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? *

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 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? (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) *

Tuberculosis Risk Assesment Questionnaire

This Risk Assesment will be reviews by a licensed health care provider (physician, physician assistant, registed nurse, nurse practionaire)

To sastify California Education Code Section 49406 and Health and Safety Code Section 121525-124555

Any history of positive TB of TB disease *

If yes, a symptom review and chest x-ray (if none performed in previous 6 months) should be performed.

If there is a "Yes" response to any of the questions #1-5 below, then an appointment must be completed to determine when a tuberculin skin test or Interferon Gamma Release Assay (IGRA) should be performed. A positive test should be followed by a chest x-ray and if no treatment for TB infection considered.

1. Do you have one or more signs and symptoms of TB *

Yes

(prolonged cough, coughing up blood, fever, night sweats, weight loss, excessive fatigue.

2. Since your last TB test have you had close contact with someone with infectious TB disease? *

Yes

3. Are you a foreign-born person? *

Yes

Any country other than United States, Canada, Australia, New Zealand or a country in Western or Northern Europe

4. Have you stayed in a high TB-prevalence country for more than 1 month since last TB test? *

Yes

Any country other than United States, Canada, Australia, New Zealand or a country in Western or Northern Europe

5. Are you a current or former resident or employee of a correctional facilty, long-term care facility, hospital or homeless shelter? *

Yes

Social Determinant Of Health Screening

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? *

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? *

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? *

Yes<br/>No

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

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

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

* Required field