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? |