Admin – MAR | 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
1073936	536	120146	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 05:40 AM	72.80	Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Safari/537.36	a4257abc-e934-480e-8cad-d5be60333e43	mar	Location	TIMOTHY CALABRO	Name	04/18/1977	Date of Birth	(917) 607-2958	Phone	Male	Gender	Rite Aid	Preferred Pharmacy Name	2064 Mill Avenue, Brooklyn, NY 11234	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).	Nasal congestion, chest congestion and cough for more than 2 weeks. Yellow mucus. COVID tests have been negative.	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Amlodipine and Rosuvastatin	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?	High Blood Pressure; High Cholesterol;	Medical History (Check all that apply or None)		Details of Other Medical History	Appendix;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Heart Disease;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History		Are you pregnant or believe you might be pregnant?		What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	No	Do you drink alcoholic beverages?	No	Do you use any recreational drugs or medications not prescribed to you?		Please specify which recreational drugs or medications you use and how often.	No	Have you traveled outside of your home state in the last 30 days?		Where did you go and when did you return?	No	Do you have a runny nose?		Describe the discharge from your nose.	Yes	Do you have a new or worsening cough?	Intermittent	Describe the frequency of cough?	Yellow	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?
1073983	536	43442	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 11:45 AM	74.11	Mozilla/5.0 (iPhone; CPU iPhone OS 16_3_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.3 Mobile/15E148 Safari/604.1	6338f3d1-505b-40c1-880d-0d0796967656	mar	Location	GIANA GAMBARO	Name	01/09/1997	Date of Birth	(347) 735-2949	Phone	Female	Gender	CVS	Preferred Pharmacy Name	4112 avenue U Brooklyn NY 11234	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).	Congestion sore throat headache	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Levothyroxine prenatal vitamins	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?	Anemia; Thyroid Disease;	Medical History (Check all that apply or None)		Details of Other Medical History	Weight Loss Surgery;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Asthma; Cancer; Depression; High Blood Pressure; High Cholesterol; 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?	09/25	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.	Yes	Have you traveled outside of your home state in the last 30 days?	9/18 - 9/24	Where did you go and when did you return?	Yes	Do you have a runny nose?	Clear	Describe the discharge from your nose.	Yes	Do you have a new or worsening cough?	Intermittent	Describe the frequency of cough?	Thin Clear	Are you coughing up phlegm?	Yes	Do you have shortness of breath?	Mild	Describe the shortness of breath.	Rarely	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.	WORK;	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?
1074050	536	100054	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 01:27 PM	173.56	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	c338fbc1-c655-43e3-89d9-a00cc5444187	mar	Location	RYAN FARRELL	Name	06/06/1996	Date of Birth	(347) 845-1266	Phone	Male	Gender	Cvs	Preferred Pharmacy Name	Ave U	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).	Ear pain eye 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?	Peanuts	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	Asthma;	Medical History (Check all that apply or None)		Details of Other Medical History	Hernia 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?	Vape/E-Cig;	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.		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?
1074087	536	119578	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 02:13 PM	69.12	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	4a28e45b-28d8-4ae4-8cef-fd6420f3bee3	mar	Location	SUSAN ROCCO	Name	11/06/1957	Date of Birth	(732) 718-3617	Phone	Female	Gender	Cvs	Preferred Pharmacy Name	4112 ave u Brooklyn 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).	Nauseous for 5 days cant keep food down	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Diltiazem 240	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Cleocin	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	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?	10 years ago	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.	Yes	Have you traveled outside of your home state in the last 30 days?	Alaska September 23	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?	Yes	Do you have intestinal (stomach) symptoms?	Nausea; Vomiting; 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.		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?
1074288	536	120249	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 11:00 PM	74.11	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	4e750a7e-0a01-47d0-9cd9-78d40e59a32f	mar	Location	DIANE MERCURI	Name	03/09/1967	Date of Birth	(718) 620-9061	Phone	Female	Gender	Rite Aid	Preferred Pharmacy Name	344 Ave x	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).	Fell and hurt my foot	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Synthroid & Diltiazem	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).	2022	What year was your last Flu Shot?	Thyroid Disease;	Medical History (Check all that apply or None)		Details of Other Medical History	C-Section; Tonsillectomy; Tubal Ligation;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Cancer; 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?	2019	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	None;	Any other smoking history?	Occasionally	Do you drink alcoholic beverages?	No	Do you use any recreational drugs or medications not prescribed to you?		Please specify which recreational drugs or medications you use and how often.	No	Have you traveled outside of your home state in the last 30 days?		Where did you go and when did you return?	No	Do you have a runny nose?		Describe the discharge from your nose.	No	Do you have a new or worsening cough?		Describe the frequency of cough?		Are you coughing up phlegm?	No	Do you have shortness of breath?		Describe the shortness of breath.		How frequent is the shortness of breath?	No	Are you having chest pain?	No	Have you lost your sense of taste or smell recently?	No	Do you have intestinal (stomach) symptoms?		Please check all your intestinal symptoms.	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?
1074420	536	120269	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 01:21 PM	108.41	Mozilla/5.0 (iPhone; CPU iPhone OS 16_6 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) GSA/283.0.567502095 Mobile/15E148 Safari/604.1	f0a52e7f-0b72-4008-b934-cf1e9d0e0cb8	mar	Location	LAURA BECKMAN	Name	11/17/1995	Date of Birth	(347) 675-1870	Phone	Female	Gender	Walgreens	Preferred Pharmacy Name	3082 Ave U, Brooklyn, NY 11229	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).	My breast/nipple is infected. I have terrible pain, a fever, and my breast looks odd	Describe any current symptoms and the reason for your visit.	No	Do you take any Prescription or Non-Prescription Medications?		List current Prescription and Non-Prescription Medications.	No	Do you have Medication or Food Allergies?		List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	None;	Medical History (Check all that apply or None)		Details of Other Medical History	None;	Surgical History (Check all that apply or None)		Details of Other Surgical History	None;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History	No	Are you pregnant or believe you might be pregnant?	9/1/23	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	Vape/E-Cig;	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	Yes	Have you had a COVID-19 vaccine?	Pfizer	Which COVID-19 vaccine did you receive?
1074574	536	120306	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 04:55 PM	24.23	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	6fceeac3-6332-43e7-9aeb-6f3cf11964ee	mar	Location	LAUREN PESSUTTI	Name	11/09/1978	Date of Birth	(646) 715-3015	Phone	Female	Gender	CVS	Preferred Pharmacy Name	4112 Ave U Brooklyn 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).	Cough nasal congestion and very sore throat	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	MVI, ETODOLAC HCTZ EFFEXOR XR MONTELUKOSAT LIPITOR LEVOTHYROXINE SUBOXONE MELATONIN OMNIPOD INSULIN PUMP	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?	Anxiety; Asthma; Arthritis; Depression; Diabetes; Seasonal Allergies;	Medical History (Check all that apply or None)		Details of Other Medical History	C-Section; Other (specify);	Surgical History (Check all that apply or None)	ORIF L FEMUR	Details of Other Surgical History	Cancer; Heart Disease; High Blood Pressure; 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?	9/4/23	What was the date of your last menstrual period?	Under a pack a day	Do you smoke cigarettes?	None;	Any other smoking history?	Socially	Do you drink alcoholic beverages?	No	Do you use any recreational drugs or medications not prescribed to you?		Please specify which recreational drugs or medications you use and how often.	Yes	Have you traveled outside of your home state in the last 30 days?	Florida 9/11/2023	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?	Intermittent	Describe the frequency of cough?	No	Are you coughing up phlegm?	No	Do you have shortness of breath?		Describe the shortness of breath.		How frequent is the shortness of breath?	No	Are you having chest pain?	No	Have you lost your sense of taste or smell recently?	No	Do you have intestinal (stomach) symptoms?		Please check all your intestinal symptoms.	No	Have you had a fever in the past 3 days?		How high was your temperature?	Yes	Do you have any Immune Disorders?	Type 1 Diabetes	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?
1074615	536	97391	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 06:12 PM	108.21	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	c5f0cb9b-cba0-42e3-8f22-d509daa2e714	mar	Location	LOREDANA SOFIA	Name	02/05/1982	Date of Birth	(718) 362-7319	Phone	Female	Gender	Cvs	Preferred Pharmacy Name	4112 Ave u	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).	Deep cough and wheezing in chest	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Paxil	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	None;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Asthma;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History	No	Are you pregnant or believe you might be pregnant?	Sept 10	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?	Constant	Describe the frequency of cough?	Yellow	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?	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?