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 patient pediatric Health & History Form Ages 5-8

Pediatric Health and History Form

Name *

Date of Birth *

Age *

Birth History

1. Birthplace:

2. Was pregnancy normal?

3. Was delivery normal?

4. Was baby full term?

5. Birth Weight?

6. Birth Length?

7. Any nursery prblem?

Growth and Development

Ages when first:

Sat:

Crawled:

Rolled:

Walked:

First teeth:

Toilet Trained:

School History

Grade in School:

Grades Averaged?

School Name:

School Problems?

Attends special school or classes?

Discipline or behavior problems?

Ever seen by psychologist, speech therapist or special teachers?

Past Medical History

Any problems with:

Sleeping?

Bedwetting?

Weight/Height?

Nail Biting?

Nightmares

Nursed or Bottle Fed?

Any Colic problems?

Use special diets?

Taking Vitamins?

Taking fluoride?

Contagious Disease? ( What Age?)

Measles?

Mumps?

Chickenpox?

Scarlet Fever?

Any Other?

Is your Child up-to-date with Vaccines?

Does your child take any medications now? ( if so, which meds?)

Hospitalizations?

(When, Where and Why)

Surgery?

(Where, When, Why?)

Serious Injuries?

(When & Where?)

Allergic Reactions:

Drugs, Asthma, Hives, Eczema, Hay Fever, Ect.,

Family History

Father: Living?

Fathers Age and Overall Health?

Health- Poor, Fair or Good

Mother Living

Mother's Age and Overall Health

Health- Poor, Fair or Good

How many Brothers/Sisters how many ?

Ages and Overall Health? Health- Poor, Fair or Good

Any Family History of :

AIDS/ HIV

Allergies

Cancer

Convulsions

Diabetes

Heart Disease

Hepatitis

How Long have your family lived in this area?

Where did you live before coming to this area?

Review of System

Check the symptoms your child had in the PAST 2 WEEKS

General

Muscle/Joint/Bone-pain, weakness, numbness. etc.,

Arms

Hands

Neck

Back

Hips

Shoulders

Feet

Legs

None

Genito-Urinary

Blood in urine

Painful urination

Frequent urination

Lack of bladder control

None

Gastroenterology

Cardiovascular

Chest pain

High blood pressure

Irregular heart beat

None

Ear, Eyes, Nose & Throat

Skin

Bruised easily

Changes in moles

Sore that won't heal

Hives

Rash

Itching

Scars

None

Medical History

When was your child's last blood test?

When was your child's las urine test?

Any special comments about your child?

Who was your child's previous doctor? (Please provide doctors name, address and phone number if known)

Staying Healthy Assessment

Please answer all the questions on this form as best as you can. Select "Skip" if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have any questions about anything on this form. Your answers will be protected as part of your medical record.

1. Does your child drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt, soy milk or tofu? *

2. Does your child eat fruits and vegetables at least two times per day? *

3. Does your child eat high fat foods, such as fried foods, chips, ice cream or pizza more than once per week? *

4. Does your child drink more than one small cup (4-6 oz.) of juice per day? *

5. Does your child drink soda, juice drinks, sports drinks, energy drinks or other sweetened drinks more than once per week? *

6. Does your child exercise or play sports most days of the week? *

7. Are you concerned about your child's weight? *

8. Does your child watch TV or play video games less than 2 hours per day? *

9. Does your home have a working smoke detector? *

10. Have you turned your water temperature down to low-warm (less than 120 degrees)? *

11. Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone? *

12. Do you always place your child in a booster seat in the back seat (or use a seat belt if your child in over 4'9")? *

13. Does your child spend time near a swimming pool, river or lake? *

14. Does your child spend time in a home where a gun is kept? *

15. Does your child spend time with anyone who carries a gun, knife or other weapon? *

16. Does your child always wear a helmet when riding a bike, skateboard or scooter? *

17. Has your child ever witnessed or been a victim of abuse or violence? *

18. Has your child been hit or hit someone in the past year? *

19. Has your child even been bullied or felt unsafe at school or in your neighborhood (or been cyber-bullied)? *

20. Does your child brush and floss her/his teeth daily? *

21. Does your child often seem sad or depressed? *

22. Does your child spend time with anyone who smokes? *

23. Do you have any other questions or concerns about your child's health or behavior? *

If yes, please describe

California Pediatric Tuberculosis Risk Assessment

Use this tool to identify asymptomatic CHILDREN for latent TB infection (LTBI) testing.

For children with TB symptoms or abnormal chest x-ray consistent with active TB disease, evaluate for active TB disease with a chest x-ray, symptom screen, and if indicated, sputum AFB smears, cultures, and nucleic acid amplification testing. A negative tuberculin skin test or interferon gamma release assay does not rule out active TB disease.

LTBI testing is recommended if any of the boxes below are checked. No TB testing needed if checked "None" *

BIRTH, TRAVEL, or RESIDENCE in a country with an elevated TB rate for at least 1 month. (Includes any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)

IMMUNOSUPPRESSION, current or planned (HIV infection, organ transplant recipient, treated with TNF-alpha antagonist [e.g., inflixamab, etanercept, others], steroids, [equivalent of prednisone >/= 2mg/kg/day for >/= weeks) or other immunosuppressive medication.)

CLOSE CONTACT to someone with infectious TB disease during lifetime.

NONE; no TB testing is indicated at this time.

Social Determinants of Health Questionnaire

Unmet social needs can negatively affect a person?s health and wellbeing. There are programs available to help, but they aren?t reaching everyone who may need them. Do you need help with any of these items?

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? *

4. Are you worried about losing your housing? *

5. Within the past 12 months, have you or the family members you live with been unable to get utilities (heat, electricity) when it was really needed? *

Transportation

6. Within the past year, has lack of transportation kept you from medical appointments, getting your medications, non-medical meetings or appointments, work or from getting the 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? *

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? *

* Required field