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Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP
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Forms
Available Forms
CHILDREN Annual depression screening PHQ 9 (Children < 18 years)
CHILDREN Registration form Dr Bharti Lalla (New Patient)
CHILDREN Sports Physical Form
CHILDREN Telemedicine Patient Consent Form (Dr Bharti Lalla Children ONLY)
CHILDREN Tuberculosis Questionnaire (Children < 18 years)
Consent for Paxlovid
Doximity telehealth Instructions
Six min WALK
zADULT Telemedicine Patient Consent Form (Dr Sunil Lalla patients)
ADULT Medical History (New Patient) Dr. Sunil Lalla
ADULT Sleep History (Dr. Sunil Lalla)
ADULT Registration form Dr S Lalla (New Patient)
Epworth sleepiness scale
CHILDREN Sports Physical Form
BHARTI LALLA, MD
First Name
*
Last Name
*
Date of Birth:
*
Date of Completion:
*
Has a doctor over denied or restricted your participation in sports for any reason?
*
-- Please Select --
Yes
No
Have you ever spent the night in the hospital ?
*
-- Please Select --
Yes
No
Have you ever had surgery ?
*
-- Please Select --
Yes
No
Have you ever passed out or nearly passed out DURING or AFTER exercise ?
*
-- Please Select --
Yes
No
Have you ever had dizziness or pressure in your chest during ecercise ?
-- Please Select --
Yes
No
Does your heart ever race or skip beats (irregular beats) during execise ?
*
-- Please Select --
Yes
No
Has a doctor ever told you thar you have any heart problems ? If so, check all that apply?
High blood pressure
High cholestrol
Has a doctor ever ordered a test for your heart ? (for exmple ECG/EKG, Echocardiogram)
*
-- Please Select --
Yes
No
Do you have lightheaded or feel more short of breath than expected during exercise?
*
-- Please Select --
Yes
No
Have you ever has an unexplained seizure ?
*
-- Please Select --
yes
No
Do you get more tired or short of breath more quickly than your friends during exercise ?
*
-- Please Select --
Yes
No
Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50(including drowning, unexplained car accident or sudden infant death syndrome?
*
-- Please Select --
Yes
No
Does anyone in your family have hypertrophic cardiomyopathy, marfan syndrome,arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular trachycardia?
*
-- Please Select --
Yes
No
Does anyone in your family have a heart problem, pacemaker or implanted defibrillator ?
*
-- Please Select --
Yes
No
Has anyone in your family had unexplained fainting, unexplained seizures or near drowing ?
*
-- Please Select --
Yes
No
Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice or game ?
*
-- Please Select --
Yes
No
Have you ever had any broken or fractured bones or dislocated joints ?
-- Please Select --
Yes
No
Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast or crutches ?
*
-- Please Select --
Yes
No
Have you ever had a stress fracture ?
*
-- Please Select --
Yes
No
New Field53
*
-- Please Select --
Yes
No
Do you regularly use a brace, orthotics, or other assistive devices ?
*
-- Please Select --
Yes
No
Do youhave a bone, muscle or joint injury that bothers you ?
*
-- Please Select --
Yes
No
Do any of your joints become painful,swollen, feel warm or look red ?
*
-- Please Select --
Yes
No
Do you have any history of juvenile arthrits or connective tissue disease ?
*
-- Please Select --
Yes
No
Do you cough, wheeze, or have difficulty breathing during or after exercise?
*
-- Please Select --
Yes
No
Have you ever used an inhaler or taken asthma medicine?
*
-- Please Select --
Yes
No
Is there anyone in your family who has asthma?
*
-- Please Select --
Yes
No
Were you born without or are you missing a kidney, an eye, a testicle( males), your spleen, or any other organ
*
-- Please Select --
Yes
No
Do you have groin pain or a painful bulge or hernia in the groin area?
*
-- Please Select --
Yes
No
Have you had infectious mononucleosis(mono) within the last month?
*
-- Please Select --
Yes
No
Do you have any rashes, pressure sores, or any other skin problems?
*
-- Please Select --
Yes
No
Have you had a herpes or MRSA skin infection?
*
-- Please Select --
Yes
No
Have you ever had a head injury or concussion?
*
-- Please Select --
Yes
No
Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
*
-- Please Select --
Yes
No
Do you have history of seizure disorder?
*
-- Please Select --
Yes
No
Do you have headaches with exercise?
*
-- Please Select --
Yes
No
Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
*
-- Please Select --
Yes
No
Have you ever been unable to move your arms or legs after being hit or falling?
*
-- Please Select --
Yes
No
Have you ever become ill while exercising in the heat?
*
-- Please Select --
Yes
No
Do you get frequent muscle cramps when exercising?
*
-- Please Select --
Yes
No
Do you or someone in your family have sickle cell trait or disease?
*
-- Please Select --
Yes
No
Have you had any problems with your eye or vision?
*
-- Please Select --
Yes
No
Have you had any eye injuries?
*
-- Please Select --
Yes
No
Do you wear glasses or contact lenses?
*
-- Please Select --
Yes
No
Do you wear protective eyewear, such as goggles or a face shield?
*
-- Please Select --
Yes
No
Do you worry about your weight?
*
-- Please Select --
Yes
No
Are yoo trying to or has anyone recommended that you lose or gain weight?
*
-- Please Select --
Yes
No
Are you on a special diet or do you avoid certain types of food?
*
-- Please Select --
Yes
No
Have you ever had an eating disorder?
*
-- Please Select --
Yes
No
Do you have any concerns that you would like to discuss with a doctor?
*
-- Please Select --
Yes
No
FEMALES ONLY
Have you ever had a menstrual period?
*
-- Please Select --
Yes
No
How old were you when you had your first menstrual period?
*
-- Please Select --
Yes
No
How many periods have you had in the last 12 months?
*
-- Please Select --
Yes
No
* Required field
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