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
990956	536	95921	0	0			0	0		03/20/2023	03/20/2023	03/20/2023 10:13 AM	71.11	Mozilla/5.0 (Macintosh; Intel Mac OS X 10_15_7) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.1 Safari/605.1.15	cbe7c952-2d1f-407b-bffa-06efc8ee1ad4	bul	Location	JILL GNERRE	Name	05/31/1979	Date of Birth	(917) 626-6718	Phone	Female	Gender	CVS	Preferred Pharmacy Name	501 Forest 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?	NO	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	sore throat, cough, chest pain	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.	Yes	Do you have Medication or Food Allergies?	levaquin	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	2023	What year was your last Flu Shot?	None;	Medical History (Check all that apply or None)		Details of Other Medical History	Adenoids; Breast Surgery; C-Section; Tonsillectomy;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Cancer; Dementia/Alzheimers; 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?	March 6	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.	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?	Yes	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?	Pfizer	Which COVID-19 vaccine did you receive?
991002	536	95924	0	0			0	0		03/20/2023	03/20/2023	03/20/2023 11:42 AM	24.17	Mozilla/5.0 (iPhone; CPU iPhone OS 16_1_2 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.1 Mobile/15E148 Safari/604.1	d6e4b635-06b0-4932-8d2a-cd9c2d93bb77	bul	Location	SUNSHINE HOPKINS	Name	05/10/1997	Date of Birth	(347) 852-7784	Phone	Female	Gender	CVS	Preferred Pharmacy Name	1933 Victory Blvd	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).	I got Covid tested last week and it was negative and i havenâ€™t been in contact with anyone who has it but I had a tiny fever and had stomach problems the last few days that have continued for weeks.	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	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?	01/05/2023	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	Vape/E-Cig; Marijuana;	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.	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?	Yes	Do you have intestinal (stomach) symptoms?	Diarrhea; Abdominal Pain;	Please check all your intestinal symptoms.	Yes	Have you had a fever in the past 3 days?	99 to 100 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	Yes	Have you had a COVID-19 vaccine?	Pfizer	Which COVID-19 vaccine did you receive?
991158	536	95951	0	0			0	0		03/20/2023	03/20/2023	03/20/2023 02:10 PM	172.58	Mozilla/5.0 (iPhone; CPU iPhone OS 15_6_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/15.6.1 Mobile/15E148 Safari/604.1	a9fa54a8-6240-4715-9b14-140e4f33aee9	bul	Location	SABRINA ORTIZ	Name	07/28/2001	Date of Birth	(917) 396-9471	Phone	Female	Gender	CVS	Preferred Pharmacy Name	1361 Hylan Blvd, 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).	-Cough, sore throat, no voice, eye pain, run down	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Unithroid, LoLoEstrin Fe	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Omnicef	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	Thyroid Disease;	Medical History (Check all that apply or None)		Details of Other Medical History	Other (specify);	Surgical History (Check all that apply or None)	Cardiac ablation	Details of Other Surgical History	Thyroid Disease;	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?	On it right now	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?	Yes	Do you have a runny nose?	Green	Describe the discharge from your nose.	Yes	Do you have a new or worsening cough?	Very Frequent	Describe the frequency of cough?	Green	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?	Moderna	Which COVID-19 vaccine did you receive?
991422	536	96058	0	0			0	0		03/20/2023	03/20/2023	03/20/2023 07:28 PM	67.25	Mozilla/5.0 (iPhone; CPU iPhone OS 16_0_3 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.0 Mobile/15E148 Safari/604.1	4ddc2e73-c86a-4b73-87b2-07edb6a40a7a	bul	Location	KRYSTYNA BLADEK	Name	08/29/1991	Date of Birth	(407) 508-4104	Phone	Female	Gender	Walgreens	Preferred Pharmacy Name	1551 Richmond avenue sI NY	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).	Strep exposure from spouse , starting to feel Iâ€™ll and would like a test and antibiotics Incase	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	N/a	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?	Anxiety; Depression;	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	Cancer; 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	No	Are you pregnant or believe you might be pregnant?	March 3 2023	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	Marijuana;	Any other smoking history?	No	Do you drink alcoholic beverages?	Yes	Do you use any recreational drugs or medications not prescribed to you?	Marijuana	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?	Thin 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?	Yes	Do you have intestinal (stomach) symptoms?	Abdominal Pain; Loss of Appetite;	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.	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?	Moderna	Which COVID-19 vaccine did you receive?
991428	536	96055	0	0			0	0		03/20/2023	03/20/2023	03/20/2023 07:34 PM	69.19	Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Safari/537.36	05155cef-12c7-489e-ae51-6f87068498bd	bul	Location	MICHELE ALTIERI	Name	01/10/1971	Date of Birth	(347) 223-3383	Phone	Female	Gender	CVS	Preferred Pharmacy Name	1654 RICHMOND AVE STATEN ISLAND NY 10314	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).	EXTREME PAIN in left shoulder going down entire arm and UTI	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; Neck Pain;	Medical History (Check all that apply or None)		Details of Other Medical History	Other (specify);	Surgical History (Check all that apply or None)	gallbladder	Details of Other Surgical History	Asthma; Cancer; Depression; 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?	2 yrs	What was the date of your last menstrual period?	Under a pack a day	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.	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	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?
991613	536	96139	0	0			0	0		03/21/2023	03/21/2023	03/21/2023 11:00 AM	24.19	Mozilla/5.0 (Linux; Android 10; SM-G960U) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Mobile Safari/537.36	2c02d75a-4b0e-41f6-81ad-70a3628d4418	bul	Location	DAVID OBRYANT	Name	10/13/1970	Date of Birth	(718) 781-2991	Phone	Male	Gender	CVS	Preferred Pharmacy Name	Union Avenue and forest Avenue	Pharmacy Street, City and State	Illness	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).	Allergic reaction	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Pacifica, Jordans	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Penicillin	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	Diabetes; High Blood Pressure;	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		Are you pregnant or believe you might be pregnant?		What was the date of your last menstrual period?	Under a pack a day	Do you smoke cigarettes?	Cigars;	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?
991645	536	96144	0	0			0	0		03/21/2023	03/21/2023	03/21/2023 12:06 PM	108.60	Mozilla/5.0 (Linux; Android 13; SM-F926U1) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Mobile Safari/537.36	2de82861-b720-4ad4-8c93-449722940e17	bul	Location	STEPHEN BEATON	Name	12/12/1966	Date of Birth	(718) 619-5113	Phone	Male	Gender	Living Well Pharmacy	Preferred Pharmacy Name	3555 victory blvd	Pharmacy Street, City and State	Injury	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).	Bit by dog difficulty moving hand	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Lunesta	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	Intestinal Surgery;	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		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.	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	Yes	Have you had a COVID-19 vaccine?	Johnson and Johnson	Which COVID-19 vaccine did you receive?