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? |