Modupe Aiyegbusi, MD

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 Genito-Urinary Gastrointestinal Cardiovascular Eye, Ear, Nose, Throat Skin Medical History Major Surgeries Any other Surgeries

Sexual Activity

Sexually Active Current Sex Partner(s) Are you interested in having STD Screening? * Children * Occupation: Drink Caffeine How Many cups of caffeine per day? Alcohol Use How many alcoholic Drinks per Week? Have you used recreational drugs? * If so, Which recreational drugs have you used? Have you ever used needles to inject drugs?

Tobacco Use:

Cigarettes Other Tobacco: Are you interested in quitting?

Other Concerns

Weight: Is your weight a concern? * Diet: How do you rate your diet? * Exercise: Do you exercise regularly? * What kind of exercise?

Past Exam and Test

Bone Density Colonoscopy Mammogram Pap Smear PSA Test Treamill (heart) Have you completed a living will or durable power of attorney for health care? * Medications: Prescriptions and Non-Prescriptions medicines, vitamins, home remedies, birth control pills and herbs Allergies or Reactions to Medicines / Food / Other Agents:

Family History

Alcohol Abuse Diabetes Breast Cancer Colon Cancer Heart Disease High Cholesterol High Blood Pressure Prostate Cancer Lung Cancer Mental Health Disorder

Adult Immunizations

Gardasil Hepatitis B Influenza ( Yearly) Pertussis Pneumonia Shingles Tetanus

Women

Date of Last Menstrual period: Do you take any of the following? Do you have any of the following symptoms?

Men

Do you have any of the following problems?

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 : * 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 * 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) *

TB Screening Questionnaire

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

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

Social Determinant Of Health Screening

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? *

NIDA Clinical Trials Network: The Tobacco, Alcohol, Prescription medications, and other Substance (TAPS) Tool

TAPS Tool Part 1

General Instructions: The TAPS Tool Part 1 is a 4-item screening for tobacco use, alcohol use, prescription medication misuse, and illicit substance use in the past year. Question 2 should be answered only by males and Question 3 only be females. Each of the four multiple-choice items has five possible responses to choose from. Check the box to select your answer.

1. In the PAST 12 MONTHS, how often have you used any tobacco product (for example, cigarettes, ecigarettes, cigars, pipes, or smokeless tobacco)? 2. In the PAST 12 MONTHS, how often have you had 5 or more drinks containing alcohol in one day? One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor. (Note: This question should only be answered by males). 3. In the PAST 12 MONTHS, how often have you had 4 or more drinks containing alcohol in one day? One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor. (Note: This question should only be answered by females). 4. In the PAST 12 MONTHS, how often have you used any drugs including marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA? 5. In the PAST 12 MONTHS, how often have you used any prescription medications just for the feeling, more than prescribed or that were not prescribed for you? Prescription medications that may be used this way include: Opiate pain relievers (for example, OxyContin, Vicodin, Percocet, Methadone) Medications for anxiety or sleeping (for example, Xanax, Ativan, Klonopin) Medications for ADHD (for example, Adderall or Ritalin)

(DO NOT COMPLETE THE NEXT SECTION IF PART 1 WAS ALL NEGATIVE)

TAPS Tool Part 2

General Instructions: The TAPS Tool Part 2 is a brief assessment for tobacco, alcohol, and illicit substance use and prescription medication misuse in the PAST 3 MONTHS ONLY. Each of the following questions and subquestions has two possible answer choices- either yes or no. Check the box to select your answer.

1. In the PAST 3 MONTHS, did you smoke a cigarette containing tobacco?

If ?Yes?, answer the following questions:

1a. In the PAST 3 MONTHS, did you usually smoke more than 10 cigarettes each day? 1b. In the PAST 3 MONTHS, did you usually smoke within 30 minutes after waking? 2. In the PAST 3 MONTHS, did you have a drink containing alcohol?

If ?Yes?, answer the following questions:

2a. In the PAST 3 MONTHS, did you have 4 or more drinks containing alcohol in a day?* (Note: This question should only be answered by females). 2b. In the PAST 3 MONTHS, did you have 5 or more drinks containing alcohol in a day?* (Note: This question should only be answered by males). 2c. In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop drinking? 2d. In the PAST 3 MONTHS, has anyone expressed concern about your drinking? 3. In the PAST 3 MONTHS, did you use marijuana (hash, weed)?

If ?Yes?, answer the following questions:

3a. In the PAST 3 MONTHS, have you had a strong desire or urge to use marijuana at least once a week or more often? 3b. In the PAST 3 MONTHS, has anyone expressed concern about your use of marijuana? 4. In the PAST 3 MONTHS, did you use cocaine, crack, or methamphetamine (crystal meth)?

If ?Yes?, answer the following questions:

4a. In the PAST 3 MONTHS, did you use cocaine, crack, or methamphetamine (crystal meth) at least once a week or more often? 4b. In the PAST 3 MONTHS, has anyone expressed concern about your use of cocaine, crack, or methamphetamine (crystal meth)? 5. In the PAST 3 MONTHS, did you use heroin?

If ?Yes?, answer the following questions:

5a. In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop using heroin? 5b. In the PAST 3 MONTHS, has anyone expressed concern about your use of heroin? 6. In the PAST 3 MONTHS, did you use a prescription opiate pain reliever (for example, Percocet, Vicodin) not as prescribed or that was not prescribed for you?

If ?Yes?, answer the following questions:

6a. In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop using an opiate pain reliever? 6b. In the PAST 3 MONTHS, has anyone expressed concern about your use of an opiate pain reliever? 7. In the PAST 3 MONTHS, did you use a medication for anxiety or sleep (for example, Xanax, Ativan, or Klonopin) not as prescribed or that was not prescribed for you?

If ?Yes?, answer the following questions:

7a. In the PAST 3 MONTHS, have you had a strong desire or urge to use medications for anxiety or sleep at least once a week or more often? 7b. In the PAST 3 MONTHS, has anyone expressed concern about your use of medication for anxiety or sleep? 8. In the PAST 3 MONTHS, did you use a medication for ADHD (for example, Adderall, Ritalin) not as prescribed or that was not prescribed for you?

If ?Yes?, answer the following questions:

8a. In the PAST 3 MONTHS, did you use a medication for ADHD (for example, Adderall, Ritalin) at least once a week or more often? 8b. In the PAST 3 MONTHS, has anyone expressed concern about your use of a medication for ADHD (for example, Adderall or Ritalin)? 9. In the PAST 3 MONTHS, did you use any other illegal or recreational drug (for example, ecstasy/molly, GHB, poppers, LSD, mushrooms, special K, bath salts, synthetic marijuana ('spice'), whip-its, etc.)?

If ?Yes?, answer the following questions:

In the PAST 3 MONTHS, what were the other drug(s) you used?