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ADULT Medical History (New Patient) Dr. Sunil Lalla

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 dat 9s)of Vaccination Enter Denied if not vaccinated
 

PREVENTATIVE CARE:

 
 
 
 
 
(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
 
 

PHQ 9 Depression screening

 

Over the last 2 weeks, how often have you been bothered by any of the following problems? (use to indicate your answer)

 
 
 
 
 
 
 
 
 
 
 
Please total questions 1 -10
 
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