Admin – TOT | 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
1074075	536	120164	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 01:59 PM	172.58	Mozilla/5.0 (iPhone; CPU iPhone OS 17_0_2 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/17.0 Mobile/15E148 Safari/604.1	2f50d566-e19a-4121-8c7d-ee76edcc3480	tot	Location	LEA KAZIU	Name	05/08/2001	Date of Birth	(718) 473-2899	Phone	Female	Gender	super health	Preferred Pharmacy Name	6390 amboy road staten island new york	Pharmacy Street, City and State	Illness	What is the reason for your visit?	No	Do you need a COVID-19 test?	Im Not Sure	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	cough, and congestion	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?	9/18/23	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?	Johnson and Johnson	Which COVID-19 vaccine did you receive?
1074096	536	120176	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 02:25 PM	172.56	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	e8d5d357-2048-4750-84c4-897f78023856	tot	Location	CHRISTOPHER TUCCIO	Name	02/25/1986	Date of Birth	(917) 916-4543	Phone	Male	Gender	Cvs	Preferred Pharmacy Name	5830 Amboy Rd, Staten Island, NY 10309	Pharmacy Street, City and State	Illness	What is the reason for your visit?	No	Do you need a COVID-19 test?	Im Not Sure	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Sore throat and cough	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?	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?	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?
1074115	536	90549	0	0			0	0		09/30/2023	09/30/2023	09/30/2023 03:05 PM	100.37	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	de9133af-85ea-4d94-bddc-eb39b363ea86	tot	Location	THOMAS MATTIOLI	Name	10/06/1993	Date of Birth	(718) 755-9438	Phone	Male	Gender	CVS pharmacy	Preferred Pharmacy Name	250 page Ave Staten Island Ny 10307	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).	Shortness of breath, congestion, cough, headache	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	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?	One pack a day	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?	White	Describe the discharge from your nose.	Yes	Do you have a new or worsening cough?	Very Frequent	Describe the frequency of cough?	Yellow	Are you coughing up phlegm?	Yes	Do you have shortness of breath?	Mild	Describe the shortness of breath.	Frequently	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.	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	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?
1074295	536	104541	0	0			0	0		09/30/2023	10/01/2023	09/30/2023 11:51 PM	68.13	Mozilla/5.0 (iPhone; CPU iPhone OS 16_6 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) CriOS/102.0.5005.67 Mobile/15E148 Safari/604.1	97a6b899-85cb-4143-8df1-29bcd1ef8f98	tot	Location	ANESA RAMADANI	Name	08/18/2000	Date of Birth	(917) 525-6164	Phone	Female	Gender	Cvs pharmacy	Preferred Pharmacy Name	2900 Veterans Rd W, Staten Island, NY	Pharmacy Street, City and State	Illness	What is the reason for your visit?	NASAL	Do you need a COVID-19 test?	NO	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Sore throat, cough, congestion	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Entyvio, Paroxetine	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; Seasonal Allergies; Other (specify);	Medical History (Check all that apply or None)	Ulcerative colitis	Details of Other Medical History	None;	Surgical History (Check all that apply or None)		Details of Other Surgical History	High Blood Pressure;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History	No	Are you pregnant or believe you might be pregnant?	9/29	What was the date of your last menstrual period?	No	Do you smoke cigarettes?	Vape/E-Cig;	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.	Yes	Do you have a new or worsening cough?	Very Frequent	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?	Yes	Do you have any Immune Disorders?	Ulcerative colitis	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?
1074343	536	120261	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 10:55 AM	73.25	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	898a14dc-37fb-45dc-a844-5e8b611121ac	tot	Location	JACOB SANTIAGO	Name	03/22/2022	Date of Birth	(941) 405-7690	Phone	Male	Gender	Walgreens	Preferred Pharmacy Name	17 Green Street Woodbridge NJ	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).	Cough, congestion, green nasal dis charge	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Zyrtec and tylenol as needed	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?	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	Cancer; Diabetes; Heart Disease; High Blood Pressure;	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?	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?	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	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?
1074344	536	120262	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 10:59 AM	73.25	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	898a14dc-37fb-45dc-a844-5e8b611121ac	tot	Location	TOMAS SANTIAGO	Name	11/22/2018	Date of Birth	(941) 405-7690	Phone	Male	Gender	Walgreens	Preferred Pharmacy Name	17 Green Street Woodbridge NJ	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).	Cough, stuffy nose, congestion	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Zyrtec and tylenol as needed	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	eggs	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	2022	What year was your last Flu Shot?	None;	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	Cancer; Diabetes; Heart Disease; High Blood Pressure; High Cholesterol;	Family History (Check all that apply to members of your immediate family or None)		Details of Other Family History		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?	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?	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.	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	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?
1074346	536	120263	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 11:03 AM	73.25	Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36	898a14dc-37fb-45dc-a844-5e8b611121ac	tot	Location	ADRIAN SANTIAGO	Name	12/04/2020	Date of Birth	(941) 405-7690	Phone	Male	Gender	Walgreens	Preferred Pharmacy Name	17 Green Street Woodbridge NJ	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).	cough, green nasal discharge, congestion	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Zyrtec and tylenol as needed	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?	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	Cancer; Heart Disease; High Blood Pressure; High Cholesterol; 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?	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?	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?	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	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?
1074396	536	81460	0	0			0	0		10/01/2023	10/01/2023	10/01/2023 12:33 PM	68.17	Mozilla/5.0 (Linux; Android 13; SAMSUNG SM-S911U) AppleWebKit/537.36 (KHTML, like Gecko) SamsungBrowser/22.0 Chrome/111.0.5563.116 Mobile Safari/537.36	ef1feea5-eade-480d-898d-eba6d30e887c	tot	Location	TIFFANI LOMUTOFEBBRARO	Name	02/15/1987	Date of Birth	(917) 854-5606	Phone	Female	Gender	Walgreens	Preferred Pharmacy Name	Rossville, Staten Island, NY	Pharmacy Street, City and State	Illness	What is the reason for your visit?	Im Not Sure	Do you need a COVID-19 test?	Im Not Sure	Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).	Sore throat, cough, congestion	Describe any current symptoms and the reason for your visit.	Yes	Do you take any Prescription or Non-Prescription Medications?	Levothyroxine	List current Prescription and Non-Prescription Medications.	Yes	Do you have Medication or Food Allergies?	Latex	List Medication and Food Allergies. Include the reaction (rash, nausea, etc).	None or Other	What year was your last Flu Shot?	Anxiety; Depression; Seasonal Allergies;	Medical History (Check all that apply or None)		Details of Other Medical History	Adenoids; C-Section; Tonsillectomy;	Surgical History (Check all that apply or None)		Details of Other Surgical History	Cancer; Dementia/Alzheimers; Depression; Diabetes; 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?	9/15/2023	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.	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?	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?	Yes	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?	Lupus	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	No	Have you had a COVID-19 vaccine?		Which COVID-19 vaccine did you receive?