Admin – FRE | 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
1073932	536	120145	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 05:17 AM	108.29	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	1f96046c-aca9-434e-b9a9-ec8abf8e7607	fre	Location	TANISHA WALKER	Name	09/15/1993	Date of Birth	(646) 652-9649	Phone	Female	Gender	CVS	Preferred Pharmacy Name	951 Atlantic Avenue Baldwin 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).	Coughing and sore throat for over a week	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).	2021	What year was your last Flu Shot?	None;	Medical History (Check all that apply or None)		Details of Other Medical History	Back 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	No	Are you pregnant or believe you might be pregnant?	9/21/2023	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.	Yes	Have you traveled outside of your home state in the last 30 days?	Go 8/30 and returned 9/4	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?	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?	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.	WORK;	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?
1073945	536	119835	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 08:20 AM	108.46	Mozilla/5.0 (iPhone; CPU iPhone OS 16_6 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.6 Mobile/15E148 Safari/604.1	cddda20a-ae23-4403-8755-09ef1024dda9	fre	Location	MICHAEL JEANPIERRE	Name	04/30/1985	Date of Birth	(646) 957-7374	Phone	Male	Gender	Walgreens	Preferred Pharmacy Name	1968 Grand Ave, Baldwin 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).	Boils on skin.	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	All from previous and what the site prescribed	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		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?	Socially	Do you drink alcoholic beverages?	No	Do you use any recreational drugs or medications not prescribed to you?		Please specify which recreational drugs or medications you use and how often.	No	Have you traveled outside of your home state in the last 30 days?		Where did you go and when did you return?	No	Do you have a runny nose?		Describe the discharge from your nose.	No	Do you have a new or worsening cough?		Describe the frequency of cough?		Are you coughing up phlegm?	No	Do you have shortness of breath?		Describe the shortness of breath.		How frequent is the shortness of breath?	No	Are you having chest pain?	No	Have you lost your sense of taste or smell recently?	No	Do you have intestinal (stomach) symptoms?		Please check all your intestinal symptoms.	No	Have you had a fever in the past 3 days?		How high was your temperature?	No	Do you have any Immune Disorders?		Whats the cause or name of the Immune Disorder?	Yes, I agree to all Terms.	I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize you to render necessary evaluation and treatment. I consent to Health Services and the HIPAA Privacy Notice. The practice will bill my insurance company for its services - if applicable. I understand that these services may or may not be considered a covered service by my insurance carrier. If the claim is denied by my insurance carrier as a non-covered service, the practice will bill me directly for the services and I am responsible for the payment of services in full. The practice may request a credit card number to be placed on file and to be used only if the medical claim is denied.		Is the COVID-19 Test for any of the following? Check all that apply.	Im not sure.	Have you been exposed to anyone with COVID-19 in the past two weeks?	Chart Number	Appointment Date	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?
1074092	536	120173	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 02:19 PM	69.11	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	2bf949e9-a6fc-4d68-9783-c127a37da3db	fre	Location	CATHERINE RICHARTZ	Name	03/10/1956	Date of Birth	(516) 996-2716	Phone	Female	Gender	Cvs	Preferred Pharmacy Name	Atlantic Ave freeport	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).	Cold and cough	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Lisinopril 5mg & atorvastatin 10mg	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?	High Blood Pressure; High Cholesterol;	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;	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?	13 years ago	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?	Yes	Do you have a runny nose?	Clear	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.	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?
1074171	536	77297	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 04:36 PM	47.20	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	f7c45fd8-f3d3-44ee-982d-660ca49dba54	fre	Location	ESCARLYN CONTRERAS	Name	04/26/2003	Date of Birth	(516) 800-5084	Phone	Female	Gender	Chubbuck s drug store	Preferred Pharmacy Name	51 S Main St Freeport, NY 11520 United States	Pharmacy Street, City and State	Illness	What is the reason for your visit?	Im Not Sure	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).	Dolor de cabeza tos y nÃ¡useas dolor en el cuerpo	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).	2023	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?	7 de September	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?	White	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?	Yes	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?	Im not sure.	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	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?
1074203	536	120206	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 05:37 PM	104.28	Mozilla/5.0 (iPhone; CPU iPhone OS 17_0 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/17.0 Mobile/15E148 Safari/604.1	55a310cb-7009-43e8-82c3-a81947ff1f5b	fre	Location	JOEL CLARKE	Name	04/25/2002	Date of Birth	(347) 703-4836	Phone	Male	Gender	Walgreens	Preferred Pharmacy Name	89 Henry St Freeport	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).	Chest pains heartburn acid reflux	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		Are you pregnant or believe you might be pregnant?		What was the date of your last menstrual period?	No	Do you smoke cigarettes?	Marijuana;	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?	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.	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?
1074261	536	120231	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 08:15 PM	96.23	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/114.0.0.0 Mobile Safari/537.36	65dbbf11-a19e-421c-bbf8-d45f0f60871e	fre	Location	BENNY CESPEDEZ	Name	11/06/1988	Date of Birth	(516) 425-8594	Phone	Male	Gender	Walgreens	Preferred Pharmacy Name	Henry st Freeport 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).	I think I have a sinus infection, I have a wheezing cough and nothing ever comes out. My ribs hurt from the coughing	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	Asthma; Diabetes;	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?	Marijuana;	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?	Im not sure.	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?
1074371	536	70405	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 12:03 PM	47.20	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	630c4bf8-a1f8-4a3d-8759-7e2e73ca8c28	fre	Location	ALONZO OKELLEY	Name	10/21/1965	Date of Birth	(163) 164-0912	Phone	Male	Gender	CVS	Preferred Pharmacy Name	114 Long Beach Ave Freeport NY	Pharmacy Street, City and State	Illness	What is the reason for your visit?	Im Not Sure	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).	Chills lost of appetite running nose cough	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	High blood pressure	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).	2023	What year was your last Flu Shot?	Heart Disease; High Blood Pressure; Kidney Disease; Stroke;	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	Cancer; Heart Disease; High Blood Pressure; Stroke;	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?	Marijuana;	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?	Yes	Do you have shortness of breath?	Moderate	Describe the shortness of breath.	Frequently	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?	Nausea; Vomiting; Loss of Appetite;	Please check all your intestinal symptoms.	Yes	Have you had a fever in the past 3 days?	Im not sure.	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.	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?	Moderna	Which COVID-19 vaccine did you receive?
1074376	536	58290	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 12:08 PM	173.52	Mozilla/5.0 (iPad; CPU OS 16_6 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) CriOS/117.0.5938.117 Mobile/15E148 Safari/604.1	167552d6-6226-4e61-bcaa-ca737f6f07df	fre	Location	FELECIA QUARLES	Name	05/20/1959	Date of Birth	(516) 428-1112	Phone	Female	Gender	CVS	Preferred Pharmacy Name	114 Long Beach Road Freeport New York 11520	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).	Constant cough and a tightness in the chest.	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Humira, Dilitiazen, Citalopram, Dexilant, Xanax, Tramadol, Ambien	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Sulfa and Ceptin	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	2023	What year was your last Flu Shot?	Anemia; Anxiety; Asthma; Arthritis; High Blood Pressure; High Cholesterol;	Medical History (Check all that apply or None)		Details of Other Medical History	Hysterectomy; Intestinal Surgery;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Asthma; High Blood Pressure; Stroke;	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?	January 200	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.		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?
1074471	536	120285	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 02:25 PM	108.29	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	dc043855-c7ea-4de9-9495-2e9931e76f59	fre	Location	KEESHA HUGHES	Name	02/09/1975	Date of Birth	(516) 841-8591	Phone	Female	Gender	CVS	Preferred Pharmacy Name	114 S. Long Beach Rd, Freeport NY	Pharmacy Street, City and State	Illness	What is the reason for your visit?	Im Not Sure	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).	Suspect that I have pink eye. Right eye is red, watery, crusty in morning, discharge.	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).	2021	What year was your last Flu Shot?	Other (specify);	Medical History (Check all that apply or None)	Early menopause	Details of Other Medical History	Other (specify);	Surgical History (Check all that apply or None)	Myomectomy 2019, DNC 2021	Details of Other Surgical History	Depression;	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?	December 2019	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	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?	Yes	Do you have a runny nose?	Clear	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.	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	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?
1074510	536	120290	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 03:21 PM	108.41	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	529cd434-a9b5-45f8-8f95-9b6feb54827c	fre	Location	PATRICIA CHIAPUZZI	Name	01/24/1961	Date of Birth	(516) 655-2500	Phone	Female	Gender	CVS	Preferred Pharmacy Name	Atlantic ave., Freeport, NY 11520	Pharmacy Street, City and State	Illness	What is the reason for your visit?	Im Not Sure	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).	Coughing and Chest congestion.	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Amlodapine	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?	Cancer; 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	Cancer; 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?	October 2019	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?	Yellow	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?	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?