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General Medicine Clinic: Dr C Osuji
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Available Forms
Agreement to Receive Chronic Care Management Services for Medicare patients
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 Vaccine Contact List
COVID-19 poner en pantalla
COVID-19 QUESTIONNAIRE
COVID-19 SCREENER
Depresión
Employment form
Flu
History - Please fill out prior to your visit. For 2nd visit and after, please update
OB/GYN ANNUAL INTAKE
Patient Health Questionnaire - Depression Screening
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
COVID-19 SCREENER
Name
*
Date of Birth
*
Phone number
*
Your Symptoms
SYSTEMIC OR DANGEROUS SYMPTOMS
Experiencing shortness of breath or trouble breathing (Dyspnea)
-- Please Select --
Yes
No
Systemic or dangerous symptoms
Abdominal pain
Chest pain
Extreme fatigue or ill feeling
Rash
Strange sound when breathing in or out
Unintentional weight loss
Urinating once or less in the past 24 hours
Vomiting or severe nausea
None of the above
Able to complete daily actiivities
Yes
Barely
No
Dyspnea severity
-- Please Select --
Very mild
Moderate
Severe
Dyspnea exacerbating factors
Coughing
Lying flat
Walking
Exerting myself
Talking
Other
None of the above
Abdominal pain severity
Mild
Moderate
Severe
Number of vomiting episodes in past 48 hours
-- Please Select --
None
Once or twice
Three or more times
Vomiting is only post-tussive
Yes
No
after cough
Able to keep fluids down
Yes
Somewhat
Not at all
Bowel movements in past day
-- Please Select --
0
1 to 2
3 to 4
5 or more
Last bowel movement
Yesterday
2 days ago
3 or more days ago
SYMPTOM COURSE
Length of present Illness (days)
Less than 1
1 to 2
3 to 4
5 to 6
7 to 9
10 to 14
15 to 21
More than 21
Current symptom severity compared to initial severity
-- Please Select --
Better
Worse
Unchanged
Has had cough during this illness
Yes
No
Has felt fevers or chills
Yes
No
Symptoms
Body aches
Diarrhea
Ear pain, pressure, or fullness
Fatigue
Headache
Itchy or red eyes
Loss of smell
Loss of taste
Nausea
Runny nose
Sinus pain
Sneezing
Sore throat
Stuffy, congested nose
Wheezing
None of the above
Chest pain severity
-- Please Select --
Mild
Moderate
Severe
Chest pain characteristics
I have had this type of pain before with cough, cold, and flu illness
I think the pain is being caused by my heart
My chest hurts even when I am not coughing
Pushing on my chest where it has been hurting causes the pain or makes it worse
The pain began before, or in the absence of, a cough
The pain is worse with exertion (e.g., walking a block or climbing stairs
When I take a deep breath, the pain becomes sever and stops me from inhaling all the way
None of the above
Still experiencing fevers or chills
-- Please Select --
Fevers
Chills
Both
Neither
Uncontrollable shaking with chills
Yes
No
Temperature taken with thermometer
Yes
No
Type of thermometer used
-- Please Select --
Mouth
Ear
Forehead
Other
Highest temperature
Below 96.8F
96.8 to 100.3F
100.4 to 102.1F
Above 102.1F
Thermometer nearby
-- Please Select --
Yes
No
Type of thermometer
Mouth
Ear
Forehead
Other
Current temperature
Below 96.8F
96.8 to 100.3F
100.4 to 102.1F
Above 102.1F
Initial temperature too low; 2nd try
-- Please Select --
Below 96.8F
96.8 to 100.3F
100.4 to 102.1F
Above 102.1F
Change in cough since beginning
Worsened
Improved
No change
I'm no longer coughing
Frequency of coughing
Constantly
Every 10 to 15 minutes
Every hour or so
Rarely
Coughing up phlegm
-- Please Select --
Yes, lots
Yes, a little
No, the cough is dry
Phlegm characteristics
Clear
Frothy or bubbly
Green
Red or rust-colored
White
Yellow
Other
Amount of hemoptysis
Occasional streaks
It's more than half blood or there are clots
It's completely blood or clots
Blood in sputum
Got flu vaccine this year
-- Please Select --
Yes
No
SOCIAL HISTORY
Recent contacts (prior 14 days) have tested positive for COVID-19
Yes
No
I'm not sure
Description of recent COVID-19 contacts
Recent sick contacts
-- Please Select --
Yes
No
Description of recent sick contacts
Smokes cigarettes or another form of tobacco
Yes
No
Has traveled out of state in the past three weeks
Yes
No
Type of travel in past three weeks
-- Please Select --
Within the U.S.
Other countries
Foreign Travel details
Medical History
TREATMENTS TRIED
Tried treatments for current symptoms
-- Please Select --
Yes
No
Which treatments
Acetaminophen (Tylenol)
Albuterol inhaler
Amoxicillin (Moxatag)
Amoxicillin-clavulanate (Augmentin)
Azithromycin (Zithromax, Z-Pak)
Benzonatate (Tessalon)
Cetirizine (Zyrtec)
Desloratadine (Clarinex)
Dextromethorphan (Robitussin)
Diphenhydramine (Benadryl)
Doxycycline
Fexofenadine (Allegra)
Guaifenesin (Mucinex)
Ibuprofen (Advil)
Levocetirizine (Xyzal)
Levofloxacin (Levaquin)
Loratadine (Claritin)
Naproxen (Aleve)
Oseltamivir (Tamiflu)
Prednisone
Pseudoephedrine (Sudafed)
Zinc tablets
Other
MEDICAL HISTORY
Has immunosuppressive condition
-- Please Select --
Yes
No
I'm not sure
Medical conditions
Asthma
Cancer
COPD
Cystic fibrosis
Diabetes
Emphysema
Heart or blood vessel disease
High blood pressure (hypertension)
High cholesterol
HIV
Kidney disease
Organ transplant
Stroke or transient ischemic attack (TIA)
Other
None of the above
FEMALE HISTORY
Pregnant or Planning
-- Please Select --
Pregnant
Planning pregnancy
No
Trimester
-- Please Select --
First
Second
Third
When planning to get pregnant
-- Please Select --
I'm trying right now
Within the next few months
Sometime this year
Next year or later
Breastfeeding
-- Please Select --
Yes
No
ANYTHING ELSE
Anything else patient would like to share
* Required field
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