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

Child/Teen Vaccine Questionnaire

Patients Name: *

Date of Birth: *

Child/Teen Date of Birth

Screening Questionnaire for Child and Teen Immunization

For Parents/Guardians: The following questions will help us determine which vaccines your child may be given today. If you answer "yes" to any questions, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

Is the child sick today? *

Does the child have allergies to latex, medications, food or any other vaccines? *

Has the child had a serious reaction to a vaccine in the past? *

Has the Child had a health problem with lungs, heart, kidney or metabolic diasease (e.g., Diabetes), asthma or a blood disorder? Is he/she on long-term Aspirin therapy? *

Has the child, a sibling or parent had a seizure, Has the child had brain or other nervous system problems? *

Does the child have cancer, leukemia, AIDS or any other immune system problem? *

In the past 3 months, has the child taken cortisone, prednisone, other steroids or anticancer drugs or had radiation treatments? *

In the past year, has the child received a transfusion of blood or blood products or been given immune (gamma) globulin or an antiviral drug? *

Is the child/teen pregnant or is there a chance she could become pregnant during the next month? *

Has the child/teen received a vaccine in the past 4 weeks? *

Did you bring your child immunization record with you? *

Form completed by: & Date: *

please type in name and relationship to child

* Required field