Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

Available Forms

ADULT Telemedicine Patient Consent Form (Dr Sunil Lalla patients) CHILDREN < 3 yearsM-Chat Form (Children age < 3 years) CHILDREN Annual depression screening PHQ 9 (Children < 18 years) CHILDREN Registration form Dr Bharti Lalla (New Patient) CHILDREN Sports Physical Form CHILDREN Tuberculosis Questionnaire (Children < 18 years) Immigration (New Patient) Immigration (New Patient) SPANISH Six min WALK ADULT Medical History (New Patient) Dr. Sunil Lalla Sleep History (Initial history) ADULT Registration form Dr S Lalla (New Patient) Sleep apnea (Epworth sleepiness scale)

Immigration (New Patient)

SUNIL LALLA, MD FCCP

Last Name *

First Name *

Sex *

Date of Birth *

Street Address *

City *

State *

ZIP code *

CITY / TOWN / VILLAGE OF BIRTH *

COUNTRY OF BIRTH *

Primary Phone Number *

Mobile Phone Number *

Email Address

USCIS Online Account Number

Alien Registration Number

Identification Information: ( Driver's License or Passport Number) *

Please provide a copy of Driver's License or Passport Number to accompany I-693

I can read and understand English *

If you do not speak English, please provide the following information about the interpreter:

Interpreter's Information

Interpreter's Name

Interpreter's Mailing Address

Interpreter's Daytime No:

Interpreter's Mobile No:

Interpreter's Email:

IMMIGATION PHYSICALS ARE NOT COVERED BY HEALTH CARE INSURANCES.

PAYMENT IS DUE AT THE TIME OF SERVICES. THANK YOU

I authorize messages to be left on voice mail and receive text messages

MEDICAL HISTORY

Illness or Injury requiring Hospitalization (including psychiatric) *

Cardiology

Hypertension

Angina

Heart Attack

Heart failure (CHF)

Valve leak

Congestive heart failure

Heart irregular beats (Fibrillation)

Rheumatic Heart Disease

Congenital heart disease

General

Fever

Cough

Night sweats

Weight loss

Psychiatry

Neurology

History of stroke

Seizure disorder

Endocrinology

Diabetes

Thyroid disease

Hematology

Anemia

Sickle Cell Disease

Thalassemia

Other hemoglobinopathy

Pulmonology

Asthma

Chronic obstructive pulmonary disease

Tobacco use: (Current or Former)

Tuberculosis history:

Specify date diagnosed (mm-yyyy) :

Tuberculosis Treatment

Specify date treatment completed (mm-yyyy) :

Sexually Transmitted Diseases

Previous treatment for sexually transmitted diseases,

Syphilis

Gonorrhea

(Syphilis Gonorrhea)

Specify date diagnosed (mm-yyyy) :

Specify date treatment completed (mm-yyyy) :

Other

Malignancy, specify:

Kidney or Bladder disease

Chronic liver disease (including hepatitis B or hepatitis C)

Hansen's Disease History

Hansen's Disease:

specify date diagnosed (mm-yyyy) and treatment: completed (mm-yyyy)

An abnormal or reactive HIV blood test

Please enter date diagnosed (mm-yyyy

Other medical conditions requiring treatment:

Food or drug allergies

(Please specify}

Disabilities

(including loss of arms or legs specify)

Current Medications

(List all current medications)

Previous Surgeries

(List all previous surgeries)

Obstetrics

Birth dates of live births (mm-dd-yyyy)

Previous live births, number:

Last Menstrual Period (females)

Pregnant, on day of exam

Estimated delivery date (mm-dd-yyyy)

Authorization: for treatment *

Signature field: *

Please print your name in the signature field

Date of Completion: *

* Required field

Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

Available Forms

Immigration (New Patient)

SUNIL LALLA, MD FCCP

Interpreter's Information

IMMIGATION PHYSICALS ARE NOT COVERED BY HEALTH CARE INSURANCES.

**PAYMENT IS DUE AT THE TIME OF SERVICES. THANK YOU**

MEDICAL HISTORY

Obstetrics

PAYMENT IS DUE AT THE TIME OF SERVICES. THANK YOU