Admin – AMI | Urgent Care Intake Forms

											Appt Date
ID	form_id	Chart #	post_id	user_id	status	type	viewed	starred	meta	Entry Date	Appt Date	date_modified	ip_address	user_agent	user_uuid	Location	Label115	Name	Label30	DOB	Label29	Phone	Label85	Q31	Label31	Q50	Label50	Q51	Label51	Reason	Label98	Test?	Label106	COV Sx	Label107	Q48	Label48	Q34	Label34	Q36	Label36	Q35	Label35	Q33	Label33	Q95	Label95	Q38	Label38	Q65	Label65	Q39	Label39	Q66	Label66	Q40	Label40	Q77	Label77	Q49	Label49	Q53	Label53	Q43	Label43	Q67	Label67	Q45	Label45	Q52	Label52	Q47	Label47	Q55	Label55	Q56	Label56	Q57	Label57	Q68	Label68	Q58	Label58	Q69	Label69	Q70	Label70	Q59	Label59	Q71	Label71	Q72	Label72	Q81	Label81	Q90	Label90	Q60	Label60	Q74	Label74	Q61	Label61	Q75	Label75	Q64	Label64	Q76	Label76	Q84	Label84	Need	Label117	Q118	Label118	Label119	Label121	Q123	Label123	Q124	Label124
1074403	536	63003	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 12:52 PM	70.23	Mozilla/5.0 (iPhone; CPU iPhone OS 16_6_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.6 Mobile/15E148 Safari/604.1	d8643b84-8427-4cfd-8d2f-3485fdbb4fd8	ami	Location	BARBARA SEIBLE	Name	05/09/1988	Date of Birth	(516) 425-7434	Phone	Female	Gender	Cvs	Preferred Pharmacy Name	Merrick rd amityville	Pharmacy Street, City and State	Other	What is the reason for your visit?	No	Do you need a COVID-19 test?	NO	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Rash	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Norethindrone and Metformin	List current Prescription and Non-Prescription Medications.	No	Do you have Medication or Food Allergies?		List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	None;	Medical History (Check all that apply or None)		Details of Other Medical History	C-Section;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Diabetes; Heart Disease; High Blood Pressure;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History	No	Are you pregnant or believe you might be pregnant?	August 28	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	Socially	Do you drink alcoholic beverages?	No	Do you use any recreational drugs or medications not prescribed to you?		Please specify which recreational drugs or medications you use and how often.	No	Have you traveled outside of your home state in the last 30 days?		Where did you go and when did you return?	No	Do you have a runny nose?		Describe the discharge from your nose.	No	Do you have a new or worsening cough?		Describe the frequency of cough?		Are you coughing up phlegm?	No	Do you have shortness of breath?		Describe the shortness of breath.		How frequent is the shortness of breath?	No	Are you having chest pain?	No	Have you lost your sense of taste or smell recently?	No	Do you have intestinal (stomach) symptoms?		Please check all your intestinal symptoms.	No	Have you had a fever in the past 3 days?		How high was your temperature?	No	Do you have any Immune Disorders?		Whats the cause or name of the Immune Disorder?	Yes, I agree to all Terms.	I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize you to render necessary evaluation and treatment. I consent to Health Services and the HIPAA Privacy Notice. The practice will bill my insurance company for its services - if applicable. I understand that these services may or may not be considered a covered service by my insurance carrier. If the claim is denied by my insurance carrier as a non-covered service, the practice will bill me directly for the services and I am responsible for the payment of services in full. The practice may request a credit card number to be placed on file and to be used only if the medical claim is denied.		Is the COVID-19 Test for any of the following? Check all that apply.	Im not sure.	Have you been exposed to anyone with COVID-19 in the past two weeks?	Chart Number	Appointment Date	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?