SUNIL LALLA, MD FCCP
PAST MEDICAL HISTORY
Please enter date (s) of Infection, If needing Hospitalization and approximate days in the hospital
PAST SURGICAL HISTORY
ALLERGIES:
Please list any additional allergies if not indicated above.
Immunization History:
Please enter Approximate date received
Please enter Approximate date received
Please enter Approximate date received
Please enter Approximate date received
Please enter Approximate date received
Please enter Approximate date received
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
Please enter date of Colonoscopy. Please enter if not completed or NA.<br/>(For patients between 50 -75 years of age.)
Please enter date of PSA for Males.Please enter NA if not applicable
Please enter date of Pap smear for Females. Please enter NA if not applicable
Please enter date of Mammogram for Females. Please enter NA if not applicable<br/>(Females biennial age 50-74)
Social History:
Cigarettes, cigars or electronic cigarettes
How many packs/day and how many years did you smoke for?
Please describe which alcohol (Wine, Beer, Rum, Vodka, Gin, Whiskey etc) do you use and the AMOUNT used/week ?
Please describe
Family History:
Medications:
Please list all medications including over the counter medications, dosage and frequency
REVIEW OF SYMPTOMS:
PLEASE CHECK BELOW ANY OF THE FOLLOWING SYMPTOMS YOU HAVE, OR HAVE HAD IN THE PAST MONTH:
Fall Risk Assessment
Please Total Questions 1 - 12
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