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 12-17 CPE - Physical forms

Child's First & Last Name *

Date of Birth *

Sex *

Grade in School *

Person filling out form: *

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-Urianry

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 minor or major surgeries

Sexual Activity

Sexually Active *

Current Sex partner(s)

Female

Male

Are you interested in having STD screening? *

Other Concerns

Weight: Is your weight a concern? *

Diet: How do you rate your diet? *

Exercise: Do you exercise regularly? *

What kind of exercise? *

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.Do you drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese yougurt, soy mimlk or tofu? *

2. Do you eat fruits and vegetables at least two times per day? *

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

4. Do you drink more than 12 oz. ( 1 soda can ) per day of juice drink, sports drink, energy drink or sweetened coffee drink? *

5. Do you exercise or play sports most days of the week? *

6. Are you concerned about your weight? *

7. Do you watch Tv or play video games less than 2 hours per day? *

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

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

10. Do you always wear a seatbelt when riding in a car? *

11. Do you spend time in a home where a gun is kept? *

12. Do you spend time with anyone who carries a gun, knife or other weapon? *

13. Do you always wear a helmet when riding a bike, skateboard or scooter? *

14. Have you ever witnessed abuse or violence? *

15. Have you been hit, slapped, kicked or physcially hurt by someone (or have you hurt someone) in the past year? *

16. Have you ever been bullied or felt unsafe at school or in your neighborhood (or cyber-bullied)? *

17. Do you brush and floss daily? *

18. Do you often feel sad, down or hopeless? *

19. Do you spend time with anyone who smokes? *

20. Do you smoke cigarettes or chew tobacco? *

21. Do you use or sniff any substance to get high, such as marijuana, cocaine, crack, methamphetamine(meth) , ecstacy, etc., ? *

22. Do you use medicines not prescribed to you? *

23. Do you drink alcohol once a week or more? *

24. If you drink alcohol, do you drink enough to get drunk or pass out?

25. Do you have friends or family members who have a problem with drugs or alcohol? *

26. Do you drive a car after drinking or ride in a car driven by someone who has been drinking or using drugs? *

Your answers about sex and family planning cannot be shared with anyone, including your parents without your permission.

27. Have you been forced or pressured to have sex? *

28. Have you ever had sex (oral, vaginal or anal)? *

If No, skip to question 35.

29. Do you think you or your partner(s) could have a sexually transmitted infection (STD), such as Chlamydia, Gonorrhea, genital warts, etc.?

30. Have you or your partner(s) had sex with other people n the past year?

31. Have you or your partner(s) had sex without using birth control in the last year?

32. The last time you had sex, did you use birth control?

33. Have you or your partner(s) had sex without a condom in the past year?

34. Did you or your partner(s) use a condom the last time you had sex?

35. Do you have concerns about liking someone of the same sex? *

36. Do you have any questions or concerns about your health? *

If Yes, Please describe:

PHQ-9: Modified for teens

Instructions: How often have you been bothered by each of the following symptoms during the past TWO WEEKS? Please select the answer that best describes how you have been feeling.

1. Feeling down, depressed, irritable or hopeless? *

2. Little interest or pleasure in doing things? *

3. Trouble falling asleep, staying asleep or sleeping too much? *

4. Poor appetite, weight loss or overeating? *

5. Feeling tired or having little energy? *

6. Feeling bad about yourself - or feeling that you are a failure. or that you have let yourself or your family down? *

7. Trouble concentrating on things like school work, reading or watching TV? *

8. Moving or speaking slowly that other people could have noticed? Or the opposite-cbeing so fidgety or restless that you were moving around a lot more than usual? *

9. Thoughts that you would be better off dead or of hurting yourself in some way? *

10. In the PAST YEAR have you felt depressed or sad most days, even if you felt okay sometimes? *

11. If you are experiencing any othe problems above , how difficult have these problems made it for you to do your work, take care of things at home or get along with people? *

12. Has there been a time in the past month when you have had serious thoughts about ending your life? *

13. Have you ever, in your whole life, tried to kill yourself or made a suicide attempt? *

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? *

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) *

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 Zealand 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)

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

3. To your knowlege, 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

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