Admin – BUL | 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
1074019	536	120152	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 12:54 PM	172.58	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/114.0.0.0 Mobile Safari/537.36	f815f7b5-74a6-4997-82c4-b4808029abf2	bul	Location	JULIE MALKO	Name	11/06/1978	Date of Birth	(347) 216-7876	Phone	Female	Gender	CVS	Preferred Pharmacy Name	1571 forest avenue. 10302	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).	Assessed boil. Infected and very painful.	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Lantus, Humalog	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?	Diabetes;	Medical History (Check all that apply or None)		Details of Other Medical History	C-Section; Tubal Ligation; Other (specify);	Surgical History (Check all that apply or None)	Shoulder	Details of Other Surgical History	Diabetes;	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?	9/24/23	What was the date of your last menstrual period?	Under a pack a day	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?	Not Sure	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	Yes	Have you had a COVID-19 vaccine?	Pfizer	Which COVID-19 vaccine did you receive?
1074083	536	120162	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 02:08 PM	24.90	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	79b507b9-c039-42b0-ae81-94946c0affc0	bul	Location	EVAN TIANVELLA	Name	08/20/2019	Date of Birth	(718) 344-9324	Phone	Male	Gender	CVS Pharmacy	Preferred Pharmacy Name	1571 Forest Avenue, Staten Island NY	Pharmacy Street, City and State	Illness	What is the reason for your visit?	No	Do you need a COVID-19 test?	Im Not Sure	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	My son has a runny nose, cough that is producing phlegm and earache, he also has complained of a headache. He doesnt have a fever.	Describe any current symptoms and the reason for your visit.	No	Do you take any Prescription or Non-Prescription Medications?		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).	2022	What year was your last Flu Shot?	None;	Medical History (Check all that apply or None)		Details of Other Medical History	None;	Surgical History (Check all that apply or None)		Details of Other Surgical History	High Cholesterol;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History		Are you pregnant or believe you might be pregnant?		What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	No	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?	Yes	Do you have a runny nose?	Clear	Describe the discharge from your nose.	Yes	Do you have a new or worsening cough?	Intermittent	Describe the frequency of cough?	No	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?	Yes	Do you have intestinal (stomach) symptoms?	Abdominal Pain;	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	Yes	Have you had a COVID-19 vaccine?	Pfizer	Which COVID-19 vaccine did you receive?
1074151	536	120191	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 04:04 PM	71.26	Mozilla/5.0 (iPhone; CPU iPhone OS 17_0_2 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/17.0 Mobile/15E148 Safari/604.1	d6d4d377-a375-4655-8f60-5310c9c2c805	bul	Location	ANNA KUSHNIR	Name	03/18/2012	Date of Birth	(212) 671-0731	Phone	Female	Gender	CVS	Preferred Pharmacy Name	2465 Richmond Ave, Staten Island, NY	Pharmacy Street, City and State	Illness	What is the reason for your visit?	No	Do you need a COVID-19 test?	YES	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Strap Throat Symptoms	Describe any current symptoms and the reason for your visit.	No	Do you take any Prescription or Non-Prescription Medications?		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	None;	Surgical History (Check all that apply or None)		Details of Other Surgical History	None;	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?	None	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	No	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.	Yes	Do you have a new or worsening cough?	Occasional	Describe the frequency of cough?	No	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.	Yes	Have you had a fever in the past 3 days?	Over 101 degrees	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?
1074250	536	120218	0	0			0	0		09/30/2023	10/01/2023	09/30/2023 07:22 PM	98.12	Mozilla/5.0 (iPhone; CPU iPhone OS 16_3 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) CriOS/117.0.5938.117 Mobile/15E148 Safari/604.1	5e7c91c1-e25a-47e4-83ee-ca73bff091a3	bul	Location	DANIELL OLIVER	Name	03/31/1998	Date of Birth	(917) 557-3125	Phone	Female	Gender	Union health	Preferred Pharmacy Name	160 W 26th street	Pharmacy Street, City and State	Illness	What is the reason for your visit?	NASAL	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).	A bad headache, and fever no cough, no sneezing, I can smell taste and can eat	Describe any current symptoms and the reason for your visit.	No	Do you take any Prescription or Non-Prescription Medications?		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).	2022	What year was your last Flu Shot?	Asthma;	Medical History (Check all that apply or None)		Details of Other Medical History	None;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Asthma;	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?	8/11/2023	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	Occasionally	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.	Yes	Have you had a fever in the past 3 days?	Over 101 degrees	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.	WORK; SCHOOL;	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	Yes	Have you had a COVID-19 vaccine?	Pfizer	Which COVID-19 vaccine did you receive?
1074300	536	120256	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 12:02 AM	71.19	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	93a64f2f-b68f-4ed4-882a-f03e64e3cd45	bul	Location	CAMILLE REDDEN	Name	09/06/1957	Date of Birth	(917) 301-4181	Phone	Female	Gender	Walgreens	Preferred Pharmacy Name	Manor road	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).	My middle finger is swollen and bruised	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Atenolol,baby aspirin,vitamin d	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Sulfur	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	Cancer; High Blood Pressure;	Medical History (Check all that apply or None)		Details of Other Medical History	C-Section; Hysterectomy; Other (specify);	Surgical History (Check all that apply or None)	Hall bladder removal	Details of Other Surgical History	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?	Totalhysterectomy	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.	Yes, I have a known contact that has COVID-19.	Have you been exposed to anyone with COVID-19 in the past two weeks?	Chart Number	Appointment Date	Yes	Have you had a COVID-19 vaccine?	Johnson and Johnson	Which COVID-19 vaccine did you receive?
1074314	536	120260	0	0			0	0		10/01/2023	09/30/2023	10/01/2023 03:33 AM	172.56	Mozilla/5.0 (iPhone; CPU iPhone OS 17_0_2 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/17.0 Mobile/15E148 Safari/604.1	3dca5611-e4fe-4586-9de9-382f920dddb2	bul	Location	WILLIAM DALY	Name	11/19/1976	Date of Birth	(718) 702-5569	Phone	Male	Gender	Cvs	Preferred Pharmacy Name	1571 Forest ave, Staten Island NY	Pharmacy Street, City and State	Illness	What is the reason for your visit?	NASAL	Do you need a COVID-19 test?	YES	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Bad cough, wheezing	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Atenolol, losartin, brilinta, rosuvastatin, baby aspirin,	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Biaxin	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	2021	What year was your last Flu Shot?	Anxiety; Heart Disease; High Blood Pressure;	Medical History (Check all that apply or None)		Details of Other Medical History	Heart Surgery;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Heart Disease; High Blood Pressure; High Cholesterol;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History		Are you pregnant or believe you might be pregnant?		What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	No	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.	Yes	Do you have a new or worsening cough?	Very Frequent	Describe the frequency of cough?	Thick Clear	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.	Other	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	Yes	Have you had a COVID-19 vaccine?	Moderna	Which COVID-19 vaccine did you receive?
1074316	536	120260	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 03:44 AM	172.56	Mozilla/5.0 (iPhone; CPU iPhone OS 17_0_2 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/17.0 Mobile/15E148 Safari/604.1	3dca5611-e4fe-4586-9de9-382f920dddb2	bul	Location	WILLIAM DALY	Name	11/19/1976	Date of Birth	(718) 702-5569	Phone	Male	Gender	Cvs	Preferred Pharmacy Name	1571 forest ave si ny	Pharmacy Street, City and State	Illness	What is the reason for your visit?	NASAL	Do you need a COVID-19 test?	YES	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Bad cough, wheeze	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Atenolol, losartin, brilinta, rosuvastatin, baby aspirin	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Biaxin	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	2021	What year was your last Flu Shot?	Anxiety; Heart Disease; High Blood Pressure;	Medical History (Check all that apply or None)		Details of Other Medical History	Heart Surgery;	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		Are you pregnant or believe you might be pregnant?		What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	No	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.	Yes	Do you have a new or worsening cough?	Very Frequent	Describe the frequency of cough?	No	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.	Im Not Sure Other	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	Yes	Have you had a COVID-19 vaccine?	Moderna	Which COVID-19 vaccine did you receive?
1074405	536	120266	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 12:56 PM	74.64	Mozilla/5.0 (iPhone; CPU iPhone OS 16_1_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.1 Mobile/15E148 Safari/604.1	367f4174-16ec-4ea1-9182-89563c5cfbe8	bul	Location	MAGDALENA ORGANISCIAK	Name	08/16/1976	Date of Birth	(516) 376-6725	Phone	Female	Gender	CVS	Preferred Pharmacy Name	Manor rd	Pharmacy Street, City and State	Illness	What is the reason for your visit?	Im Not Sure	Do you need a COVID-19 test?	Im Not Sure	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Cough	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Letrozole	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).	2021	What year was your last Flu Shot?	Cancer;	Medical History (Check all that apply or None)		Details of Other Medical History	Breast Surgery;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Diabetes;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History	Yes	Are you pregnant or believe you might be pregnant?	2018	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	No	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.	Yes	Do you have a new or worsening cough?	Intermittent	Describe the frequency of cough?	No	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.	Yes	Have you had a fever in the past 3 days?	100 to 101 degrees	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.	Other	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	Yes	Have you had a COVID-19 vaccine?	Pfizer	Which COVID-19 vaccine did you receive?
1074561	536	120303	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 04:42 PM	104.28	Mozilla/5.0 (iPhone; CPU iPhone OS 17_0_2 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/17.0 Mobile/15E148 Safari/604.1	6402cae4-0f1e-4b26-9ad8-05454ec0d48f	bul	Location	CLAUDIA SOUFFRONT	Name	03/28/1979	Date of Birth	(347) 777-5188	Phone	Female	Gender	CVS pharmacy	Preferred Pharmacy Name	1933 Victory Blvd Staten Island NY	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).	On Thursday 9/28 single strip rash the side of the body a small itchy blister with Flu like symptoms Fatigue and pain entire body By Friday 9/29 little red bumps that are itchy and painful aperread	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Fluticasone propionate nasal spray	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Aspirin - bruises. Seasonal allergies including hay hever	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	2023	What year was your last Flu Shot?	Anemia; High Cholesterol; Seasonal Allergies;	Medical History (Check all that apply or None)		Details of Other Medical History	Other (specify);	Surgical History (Check all that apply or None)	Plastic surgery on abdomen	Details of Other Surgical History	Diabetes; High Blood Pressure; High Cholesterol;	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?	9/2/2023	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.	Yes	Have you had a fever in the past 3 days?	100 to 101 degrees	How high was your temperature?	Not Sure	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	Yes	Have you had a COVID-19 vaccine?	Pfizer	Which COVID-19 vaccine did you receive?