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

Ages 9-11 CPE Physical forms

Child's First and Last Name *

Date of Birth *

Grade in School *

Sex *

Person completing form *

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 yougurt, soy mimlk 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 cup (8oz) of juice per day? *

5. Does your child dronk soda, juice drinks, sport 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 dectetor? *

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

11. Do your child always use a seat belt in the back seat (or use a booster seat if under 4'9") *

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

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

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

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

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

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

18. Has your child ever been bullied, felt unsafe at school or in your neighborhood ( or been cyber-bullied)? *

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

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

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

22. Has your child ever smoked cigarettes or chewed tobacco? *

23. Are you concerned your child may be using drugs or sniffing substances such as glue to get high? *

24. Are you concerned that your child may be drinking alcohol, such as beer, wine, wine coolers or liquor? *

25. Does your child have friends or family members who has problems with drugs or alcohol? *

26. Has your child started dating or " goint out" with boyfriend or girlfriends? *

27. Do you think your child might be sexually active? *

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

If yes, Please describe:

Review of System

Pediatric Wellness- 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

Gastroenterology *

CardioVascular *

Chest pain

High blood pressure

Irregular heart beat

Ear, Eyes, Nose & Throat *

Skin *

Bruise easily

Hives

Itching

Changes in moles

Rash

Scars

Sore that wont heal

Medical History *

Any major surgeries? *

GAD 7- 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? *

2. Not being able to stop or control worrying? *

3. Worrying too much about different things? *

4. Trouble Relaxing? *

5. Being to restless that it's hard to sit still? *

6. Becoming easily annoyed or irritable? *

7. Feeling afraid as if something awful might happen? *

Total Score *

If you checked off any problems, how difficult have these made it for you to do work, take care of things at homeor get along with other people? *

Pediatric TB Risk Assesment

1. Was your child born in a high-risk country? (choose one) *

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

2. Has your child traveled to a high-risk country for more than 1 week? (choose one) *

3. To your knowledge, has your child been exposed to anyone with TB disease? (choose one) *

4. Has a family member had a positive TST or IGRA result? (choose one) *

Social Determinants Of Health Screening

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? (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? *

E-HITS Domestic Violence Screening (For Age 11 and Over)

Please read each of the following activities and select the option that best indicates the frequency with which your partner acts in the way depicted.

Over the last 12 months, how often did your partner:

1. Physically hurt you? *

2. Insult you or talk down to you? *

3. Threaten you with harm? *

4. Scream or curse at you? *

5. Force you to have sexual activities? *

Total Score: __________ (0-25) *

Each item is scored from 1-5. Range is between 5-25. A score greater than 10 signify that you are at risk of domestic violence abuse, and should seek counseling or help from a domestic violence resource center such as the following: National Domestic Violence Hotline - 1.800.799.SAFE (7233) Women's and Children's Crisis Shelter - 562.945.3939 East LA Women's Center (ELAWC) - 800.585.6231 WomenShelter of Long Beach - 562.437.4663

* Required field