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

Flu Vaccine Questionnaire 21-22

Name: *

Date of Birth: *

For patient (both children and adult) to be vaccinated: The following questions will help us to determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer "yes" to any questions, it does not necessarily mean you (or 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 person to be vaccinated sick today? *

Does the person to be vaccinated have an allergy to an ingredient of the vaccine? *

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Has the person to be vaccinated ever had a serious reaction to the influenza vaccine in the past? *

Has the person to be vaccinated ever had Guillain-Barre Syndrome? *

* Required field