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

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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)

ADULT Medical History (New Patient) Dr. Sunil Lalla

SUNIL LALLA, MD FCCP

First Name *

Last Name *

Date of Birth: *

Reason for Appointment & Current Complaints:

PAST MEDICAL HISTORY

Do you suffer from?

Hypertension *

Diabetes Mellitus

Taking insulin

Not taking insulin

High Cholesterol *

Heart Disease

Angina

Heart Attack

Heart failure (CHF)

Valve leak

Congestive heart failure

Heart irregular beats (Fibrillation)

Date of Stent or Angioplasty or Bypass Surgery

Heart attack

COPD Emphysema Chronic bronchitis *

Other lung diseases

Interstitial lung disease

Pulmonary Hypertension

Asthma *

Blood clots Embolism phlebitis *

Tuberculosis Positive skin test TBc *

Previous COVID Infection

Please enter date (s) of Infection, If needing Hospitalization and approximate days in the hospital

Liver Disease

Liver Disease

Hepatitis

Cirrhosis

Fatty liver disease

Autoimmune hepatitis

Gall Bladder

Stroke or TIA

Stroke

TIA

Convulsions Seizures

Brain Aneurysm

Kidney disease

Kidney disease

Kidney Stones

Dialysis

Cancer: Location Treatment

Mental disease

Dementia

Depression

Others

HIV

Sickle cell disease

Gastrointestinal

Reflux

Hiatal hernia

Gastritis

Ulcers Bleeding

Ulcers Not bleeding

Other

Osteoporosis *

Arthritis *

Thyroid disease *

Please list any other medical problems:

PAST SURGICAL HISTORY

Please list prior surgeries:

Any other Surgeries not listed

ALLERGIES:

List Allergies *

None

ACE agents

Codeine

Penicillin

Sulfa

Other - List Below

Other Allergies

Please list any additional allergies if not indicated above.

Immunization History:

Influenza (Flu) Vaccine received *

INFLUENZA

Please enter Approximate date received

Pneumonia (Pneumococcus 23) Vaccine received *

PNEUMOVAX 23

Please enter Approximate date received

Prevnar 13 vaccine received *

PREVNAR 13 (NEW PNEUMONIA)

Please enter Approximate date received

Shingles vaccine received *

SHINGLES

Please enter Approximate date received

Tetanus / Whooping cough received *

TETANUS

Please enter Approximate date received

WHOOPING COUGH

Please enter Approximate date received

COVID Vaccination & Booster dose(s) with dates

Please enter dates of Vaccination and Booster(s) Please enter denied if not vaccinated

PREVENTATIVE CARE:

Please enter 01/01/1900 if not applicable or completed

Height *

Weight *

Colonoscopy *

Please enter date of Colonoscopy. Please enter if not completed or NA.<br/>(For patients between 50 -75 years of age.)

MALES PSA

Please enter date of PSA for Males.Please enter NA if not applicable

FEMALE PAP Smear

Please enter date of Pap smear for Females. Please enter NA if not applicable

Females Mammogram *

Please enter date of Mammogram for Females. Please enter NA if not applicable<br/>(Females biennial age 50-74)

Social History:

Have you ever smoked? *

Cigarettes, cigars or electronic cigarettes

Date when you started smoking?

Date when you did stop smoking?

How many packs per day and for how long ?

How many packs/day and how many years did you smoke for?

Do you drink alcohol?

Please describe which alcohol (Wine, Beer, Rum, Vodka, Gin, Whiskey etc) do you use and the AMOUNT used/week ?

How many times have you had more than 4 drinks/day? *

Do you use recreational drugs?

Please describe

Do you have a Living Will *

Name / Contact Information of Health Care Surrogates

Family History:

Diseases that run in Family

Hypertension

Diabetes

Heart Disease

Cancer

Stroke

High cholesterol

FATHER LIVING *

CAUSE OF DEATH / MEDICAL CONDITIONS

MOTHER LIVING *

CAUSE OF DEATH / MEDICAL CONDITIONS

SIBLING LIVING *

MEDICAL CONDITIONS

CHILDREN LIVING *

MEDICAL CONDITIONS

Medications:

Please list all medications including over the counter medications, dosage and frequency

Medications *

Medications additional

REVIEW OF SYMPTOMS:

PLEASE CHECK BELOW ANY OF THE FOLLOWING SYMPTOMS YOU HAVE, OR HAVE HAD IN THE PAST MONTH:

Constitutional:

Fevers / Chills

Night Sweats

Weight Gain Loss

Appetite Increased /Decreased

Eyes / Ears / Throat

Blurring of vision

Decreased hearing

Discharge from eyes / ears

Post nasal drip

Sinus congestion

Respiratory:

Cough

Sputum / Phlegm

Shortness of Breath

Wheezing

Pain with Breathing

Coughing up Blood

How many times have you had 4 or more drinks a day

Sleep Disorders:

Snoring

Daytime sleepiness/fatigue

Morning stiffness

Lack of concentration /irritability

Cardiovascular:

Chest pain/tightness

Arm pain

Palpitations

Feet swelling

Waking up with shortness of breath

Gastrointestinal:

Abdominal pain

Constipation

Diarrhea

Heartburn

Nausea / vomiting

Vomiting blood

Rectal bleeding

Black stools

Hemat/Lymphatic

Anemia

Bleeding tendencies

Easy skin bruising

Lymph node swelling

Musculoskelectal

Neck / back pain

Muscle weakness

Joint swelling

Endocrine:

Heat / cold intolerance

Thyroid disorders

Diabetes

Neurology:

Balance problems

Muscle weakness

Headaches

Tingling / numbness

Tremor

Skin:

Skin Rash

Skin Nodule

Change in Mole Size

Genitourinary:

Painful urination

Blood in urine

Urinating more often

Urinating incontinence

Lump in testicle (men)

Penile discharge (men)

Urinary stream (men)

Breast lumps / discharge

Vaginal discharge(women)

Fall Risk Assessment

1. I have fallen in the past year.* *

2. I use or have been advised to use a cane or walker to get around safely.* *

3. Sometimes I feel unsteady when I am walking.* *

4. I steady myself by holding onto furniture when walking at home *

5. I am worried about falling. *

6. I need to push up with my hands to stand up from a chair. *

7. I have some trouble stepping up onto a curb* *

8. I often have to rush to the toilet. *

9. I have lost some feeling in my feet* *

10. I take medicine that sometimes makes me feel light-headed or more tired than usual.* *

11. I take medicine to help me sleep or improve my mood.* *

12. I often feel sad or depressed* *

FALL RISK TOTAL: *

Please Total Questions 1 - 12

Signature *

Please print your name in the signature field. Typing your name will be counted as an electronic signature. I am the individual who has typed their name actually signed the document.

* Required field