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

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 Depression screen and Fall Risk Assessment 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)

zADULT Depression screen and Fall Risk Assessment

SUNIL LALLA, MD FCCP

First Name *

Last Name *

Date of Birth *

Date of Completion *

Please answer all the questions below: All questions with * are required.

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

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)

1. Little interest or pleasure in doing things *

2. Feeling down, depressed, or hopeless *

3. Trouble falling or staying asleep, or sleeping too much *

4. Feeling tired or having little energy *

5. Poor appetite or overeating *

6. Feeling bad about yourself or that you are a failure or have let yourself or your family down *

7. Trouble concentrating on things, such as reading the newspaper or watching television *

8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual *

9. Thoughts that you would be better off dead, or of hurting yourself *

10. How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?* *

DEPRESSION SCREEN TOTAL: *

Please total questions 1 -10

* Required field