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 náuseas 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? |