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

Medicare Wellness

Patient Name *

Date of Birth *

Marital Status *

Do you have an Advanced Directive? *

For your Annual Medicare Wellness Visit

Staying Healthy Assessment

Please answer all the questions on this form as best as you can. Click/circle "Skip" if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have 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, yogurt, soy milk or tofu? *

2. Do you eat fruits and vegetables every day? *

3. Do you limit the amount of fried food or fast food that you eat? *

4. Are you easily able to get enough healthy food? *

5. Do you drink soda, juice drink, sports or energy drinks most days of the week? *

6. Do you often eat too much or too little food? *

7. Do you have difficulty chewing or swallowing? *

8. Are you concerned about your weight? *

9. Do you exercise or spend time doing activities, such as walking, gardening or swimming for at least 1/2 hour a day? *

10. Do you feel safe where you live? *

11. Do you often have trouble keeping track of your medicines? *

12. Are family members or friends worried about your driving? *

13. Have you had any car accidents lately? *

14. Do you sometimes fall and hurt yourself or is it hard to get up? *

15. Have you been hit, slapped, kicked or physically hurt by someone in the past year? *

16. Do you keep a gun in your house or place where you live? *

17. Do you brush or floss your teeth daily? *

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

19. Do you often have trouble sleeping? *

20. Do you or others think that you are having trouble remembering things? *

21. Do you smoke or chew tobacco? *

22. Do friends or family members smoke in your house or where you live? *

23. In the past year, have you had 4 or more alcohol drinks in one day? *

24. Do you use any drugs or medicines to help you sleep, relax, calm down, feel better or lose weight? *

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

26. Have you or your partner(s) had sex with other people in the past year? *

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

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

29. Do you have someone to help you make decisions about your health and medical care? *

30. Do you need help bathing, eating, walking, dressing or using the bathroom? *

31. Do you have someone to call when you need help in an emergency? *

32. Do you have other questions or concerns about your health? *

If yes, please describe:

Activities of Daily Living (ADL)

Using Telephone *

I= Able to look up numbers, dial, receive and make calls without help

A= Able to answer phone or dial operator in an emergency but needs special phone or help in getting number, dialing

D= Unable to use phone

Traveling *

I= Able to drive own car or travel alone on bus or taxi

A= Able to travel but needs someone to travel with

D= Unable to travel

Shopping *

I= Able to take care of all food/clothes shopping

A= Able to shop but needs someone to shop with

D= Unable to shop

Preparing Meals *

I= Able to plan and cook meals

A= Able to prepare light foods but unable to cook full meals alone

D= Unable to cook

Housework *

I= Able to do heavy housework. (i.e. Scrub floors)

A= Able to do light housework, but needs help with heavy tasks

D= Unable to do any housework

Taking Medicines *

I= Able to prepare/take medications in the right dose at the right time

A= Able to take medication, but needs reminding or someone to prepare them

D= Unable to take medications

Managing Money *

I= Able to manage buying needs. (i.e. Write checks, pay bills)

A= Able to manage daily buying needs but needs help managing checkbook, paying bills

D= Unable to manage money

Hearing

Do you have a hearing problem? *

Safety & Fall Risk Assessment

1. Have you fallen in the past 6 months? *

2. If you answered Yes to question #1, were you injured?

3. Have you experienced urgency or frequency with elimination in the past 6 months *

4. Have you expirienced episodes of dizziness in the past 6 months? *

5. Do you use any assitive devices for ambulation? *

5a. If you answered YES, Please check off the device used

Another Person

Railing

Cane

Walker

Wheelchair

6. Do you feel you could benefit from installing grab bars on your tub and/or shower? *

7. Does your home lack smoke detectors or sprinklers? *

8. Do you sometimes forget to fasten your seat belt when traveling in a car? *

9. Does your home have a fireplace? *

10. Do you smoke? *

11. Do you drink alcohol at least twice a week? *

12. Do you use oxygen on a regular basis? *

13. Does your home lack a fire extinguisher? *

14. Do you use scatter rugs throughout your home? *

15. Does your home have a pool or hot tub? *

PHQ9

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Little Interest or Pleasure in doing things? *

Feeling down, depressed or hopeless *

Trouble falling/staying asleep or sleeping too much *

Feeling tired or having little energy *

Poor appetite or overeating *

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

Trouble concentrating on things, such as reading the newspaper or watching television *

Moving or speaking slowly that other people could have noticed. Or the opposite- being so fidgety or restless that you have been moving around more than usual *

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

If you checked off ANY problem on this questionnaire so far, How difficult have these problems made it for you to do your work, take care at home or get along with other people? *

Total Score *

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? (choose one) *

5. Being so 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) *

PAIN SURVEY

Many people have pain, but do not discuss with their doctors. We encourage you to fill out the the questionnaire below. Your answers will be sent to the doctor so that you can discuss these problems at your visit.

Gender *

Male

Female

Age *

In the last week, on average, How would you rate your pain? *

use scale 0-10, where 0 is "no pain" and 10 is "pain as bad as could be" ( That is, Your usual pain when you were in pain.")

In the last month, How much has pain interfered with your daily activities? *

Use scale from 0-10, where 0 is "No interference" and 10 is "unable to carry on any activities"

How long have you had the pain? *

in days, weeks, months or year

I currently: *

Am not working

Work Part-Time

Work Full-Time

How many days in the past month have you been bothered by pain with doing daily activities? *

How many days in the past month have you missed doing daily activities due to pain? *

Overall , How satisfied are you with your current pain medications? *

Overall, How does your level of pain relief meet your expectations of pain relief? *

Over Active Bladder ( Urinary Incontinence or Frequent Urination) Awareness Tool

Many people are bothered by bladder symptoms, but may be reluctant to discuss these problems with their doctors. We encourage you to fill out the questionnaire below.

During the past 4 weeks, how bothered were you by:

Frequent urination during the daytime hours *

An uncomfortable urge to urinate *

A sudden urge to urinate with little or no warning *

Accidental loss of small amounts of urine *

Night time urination *

Waking up at night because you had to urinate *

An uncontrollable urge to urinate *

Urine loss associated with a strong desire to urinate *

Do you currently take any medication for bladder symptoms? *

How many times do you get up at night to use the bathroom? *

TB Screening Questionnaire

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

LTBI Testing is recommended if any of the boxes below are checked, no TB testing 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

HOMELESSNESS OR INCARCERATION (current or past). Persons experiencing homelessness or residing in high-risk congregated settings including homelessness shelter or correctional facility during lifetime.

IMMUNOSUPPRESSION (current or planned), HIV infection, organ transplant recipient, treated with biological agents including TNF-alpha antagonist (e.g., inflixamab, adalimumab, etanercepts, others), steroids (equivalent of prednisone 15mg/day for 1 month) or other immunosuppressive medication.

CLOSE CONTACT to someone with infectious TB disease during lifetime.

NONE; no TB testing indicated at this time.

Social Determinants Of Health Screening

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 your family members you live with been unable to get utilities (heat, electricity) 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 and emotionally safe where you 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 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? *

The Tobacco, Alcohol, Prescription medications, and other Substance (TAPS) Tool

TAPS Tool Part 1

The TAPS Tool Part 1 is a 4-item screening for tobacco use, alcohol use, prescription medication misuse, and illicit substance use in the past year. Question 2 should be answered only by males and Question 3 only be females. Each of the four multiple-choice items has five possible responses to choose from. Check the box to select your answer

1. In the PAST 12 MONTHS, how often have you used any tobacco product (for example, cigarettes, ecigarettes, cigars, pipes, or smokeless tobacco)?

Daily or Almost Daily

Weekly

Monthly

Less Than Monthly

Never

2. (MALES ONLY) In the PAST 12 MONTHS, how often have you had 5 or more drinks containing alcohol in one day? One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor.

Daily or Almost Daily

Weekly

Monthly

Less Than Monthly

Never

3. (FEMALES ONLY) In the PAST 12 MONTHS, how often have you had 4 or more drinks containing alcohol in one day? One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor.

Daily or Almost Daily

Weekly

Monthly

Less Than Monthly

Never

4. (FEMALES ONLY) In the PAST 12 MONTHS, how often have you used any drugs including marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA?

Daily or Almost Daily

Weekly

Monthly

Less Than Monthly

Never

5. In the PAST 12 MONTHS, how often have you used any prescription medications just for the feeling, more than prescribed or that were not prescribed for you? Prescription medications that may be used this way include: Opiate pain relievers (for example, OxyContin, Vicodin, Percocet, Methadone) Medications for anxiety or sleeping (for example, Xanax, Ativan, Klonopin) Medications for ADHD (for example, Adderall or Ritalin)

Daily or Almost Daily

Weekly

Monthly

Less Than Monthly

Never

TAPS Tool Part 2

The TAPS Tool Part 2 is a brief assessment for tobacco, alcohol, and illicit substance use and prescription medication misuse in the PAST 3 MONTHS ONLY. Each of the following questions and subquestions has two possible answer choices- either yes or no. Check the box to select your answer.

1. In the PAST 3 MONTHS, did you smoke a cigarette containing tobacco?

Yes

1.1) If ?Yes?, answer the following questions:

1.1) a. In the PAST 3 MONTHS, did you usually smoke more than 10 cigarettes each day?

Yes

1.1) b. In the PAST 3 MONTHS, did you usually smoke within 30 minutes after waking?

Yes

2. In the PAST 3 MONTHS, did you have a drink containing alcohol?

Yes

2.1) If ?Yes?, answer the following questions:

2.1). A. (FEMALES ONLY) In the PAST 3 MONTHS, did you have 4 or more drinks containing alcohol in a day?*

Yes

*One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor

2.1). B. (MALES ONLY) In the PAST 3 MONTHS, did you have 5 or more drinks containing alcohol in a day?*

Yes

*One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor

2.1). C. In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop drinking?

Yes

2.1). D. In the PAST 3 MONTHS, has anyone expressed concern about your drinking?

Yes

3. In the PAST 3 MONTHS, did you use marijuana (hash, weed)?

Yes

3.1) If ?Yes?, answer the following questions:

3.1) A. In the PAST 3 MONTHS, have you had a strong desire or urge to use marijuana at least once a week or more often?

Yes

3.1) B. In the PAST 3 MONTHS, has anyone expressed concern about your use of marijuana?

Yes

4. In the PAST 3 MONTHS, did you use cocaine, crack, or methamphetamine (crystal meth)?

Yes

4.1) If ?Yes?, answer the following questions:

4.1) A. In the PAST 3 MONTHS, did you use cocaine, crack, or methamphetamine (crystal meth) at least once a week or more often?

Yes

4.1) B. In the PAST 3 MONTHS, has anyone expressed concern about your use of cocaine, crack, or methamphetamine (crystal meth)?

Yes

5. In the PAST 3 MONTHS, did you use heroin?

Yes

5.1) If ?Yes?, answer the following questions:

5.1) A. In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop using heroin?

Yes

5.1) B. In the PAST 3 MONTHS, has anyone expressed concern about your use of heroin?

Yes

6. In the PAST 3 MONTHS, did you use a prescription opiate pain reliever (for example, Percocet, Vicodin) not as prescribed or that was not prescribed for you?

Yes

6.1) If ?Yes?, answer the following questions:

6.1) A. In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop using an opiate pain reliever?

Yes

6.1) B. In the PAST 3 MONTHS, has anyone expressed concern about your use of an opiate pain reliever?

Yes

7. In the PAST 3 MONTHS, did you use a medication for anxiety or sleep (for example, Xanax, Ativan, or Klonopin) not as prescribed or that was not prescribed for you?

Yes

7.1) If ?Yes?, answer the following questions:

7.1) A. In the PAST 3 MONTHS, have you had a strong desire or urge to use medications for anxiety or sleep at least once a week or more often?

Yes

7.1) B. In the PAST 3 MONTHS, has anyone expressed concern about your use of medication for anxiety or sleep?

Yes

8. In the PAST 3 MONTHS, did you use a medication for ADHD (for example, Adderall, Ritalin) not as prescribed or that was not prescribed for you?

Yes

8.1) If ?Yes?, answer the following questions: (Copy)

8.1) A. In the PAST 3 MONTHS, did you use a medication for ADHD (for example, Adderall, Ritalin) at least once a week or more often?

Yes

8.1) B. In the PAST 3 MONTHS, has anyone expressed concern about your use of a medication for ADHD (for example, Adderall or Ritalin)?

Yes

9. In the PAST 3 MONTHS, did you use any other illegal or recreational drug (for example, ecstasy/molly, GHB, poppers, LSD, mushrooms, special K, bath salts, synthetic marijuana ('spice'), whip-its, etc.)?

Yes

9.1) If ?Yes?, answer the following questions:

9.1) In the PAST 3 MONTHS, what were the other drug(s) you used?

Smoking History

History of Smoking? *

If so, how many years?

How many Cigs. per day?

When did you quit?

Medical History

Previous Medical History:

Medical Specialists

List all the specialists you are seeing:

Hospitalizations

List any recent hospitalizations:

Medication List

List any medications you are taking including: DOSE and DIRECTIONS. List over the counter (OTC) medications as well:

* Required field