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

Tuberculosis Risk Assesment Questionnaire

California Adult Tuberculosis Risk Assessment

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

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

Name *

Date of Birth *

Today's Date *

LTBI testing is recommended if any of the boxes below are checked. No TB testing is 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 greater then equal to 15mg/day for greater then or equal to 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

* Required field