General Medicine Clinic: Dr C Osuji

Available Forms

Agreement to Receive Chronic Care Management Services for Medicare patients Appointment request Asthma Control Test Balance self-test (please fill prior to every visit and press send) por favor, llene antes de cada visita y pulse enviar Checklist for Medicare Annual Wellness Visit Controlled med contract Cough/cold/sinus infection COVID-19 Patient Screening Questionnaire COVID-19 poner en pantalla COVID-19 QUESTIONNAIRE COVID-19 SCREENER Depresión Employment form Espanol vacuna COVID-19 Flu History - Please fill out prior to your visit. For 2nd visit and after, please update New patient form New pt Spanish OB/GYN ANNUAL INTAKE Patient Health Questionnaire - Depression Screening Patient/Health Care Provider E-mail/Texting Consent Reason for your next office visit Record request Referral request (requests are processed in 5 working business days) If urgent request needed, please call office to pick up btw 12 noon at 4 pm Refill request Spanish New Patient Telehealth Consent Telephone or message Consultation (for Clinic patients only) Video conference for patients VITALS

Balance self-test (please fill prior to every visit and press send) por favor, llene antes de cada visita y pulse enviar

Please pick (por favor escoge)

Have you fallen in the past 12 months? (Se ha caido en el último año?)

Please pick (por favor escoge)

Do you feel dizzy or off balance if you make a sudden change in movement, such as bending down or quickly turning? (Se siente mareado o pierde el equilibrio si realiza un cambio repentino en movimiento, como agacharse o girar rápidamente?)

Please pick (por favor escoge)

Do you have hearing loss? (Ha tenido cambios en su audición como pérdida o disminución?)

Please pick (por favor escoge)

Do you require assistance to walk, such as a person supporting you, use a walker or a wheelchair? (Necesita ayuda para caminar como una persona para apoyo, un andador o silla de ruedas)

Please pick (por favor escoge)

Do you have balance problems when you are walking or climbing stairs? (Tiene problemas de equilibrio cuando camina o subiendo escaleras?)

Name (Nombre) *

Date (Fecha) *

Phone number (Número de teléfono) *

* Required field