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Completed COVID Vaccine Doses
Yes / No
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Drug Test
COVID-19 Antigen Test
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Post-holiday Package
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Doctor Consult (Telemedicine)
Internal Medicine (Telemedicine)
Cardiology Consult (Telemedicine)
Doctor Consult (Face-to-face)
Internal Medicine (Face-to-face)
Cardiology Consult (Face-to-face)
Pap smear
Incision and Drainage
Circumcision
Removal of suture
Removal of cyst
Removal of warts
Removal of lipoma
12-L ECG
2D Echocardiography
2D Echocardiography w/ Doppler Study
Abdomen Lower UTZ
Abdomen Upper UTZ
Abdomen Whole UTZ
Breast UTZ
Gallbladder UTZ
Guided Biopsy UTZ
Hemithorax UTZ
Kidneys UTZ
KUB UTZ
LGBPS/HBT UTZ
Liver UTZ
Neck UTZ
Pancreas UTZ
Prostate UTZ
Transrectal Prostate UTZ
Scrotal (w/ Color Study) UTZ
Scrotal Doppler (Plain) UTZ
Scrotal UTZ
Soft Tissue (Lower Extremities) UTZ
Spleen UTZ
Thyroid (w/o Doppler) UTZ
Thyroid (w/ Color Doppler) UTZ
X-ray/Radiology
Pneumonia Vaccination (PCV 13)
Pneumonia Vaccination (PPSV 23)
Flu Vaccination (Quadrivalent)
Flu Vaccination (Trivalent)
Varicella/Chickenpox Vaccination
TDaP Vaccination
MMR Vaccination
Hepa B Vaccination
Hepa A Vaccination
Tetanus Vaccination
Rabies Vaccination
Japanese Encephalitis
Meningococcal Vaccine
Typhoid Vaccination
Other Vaccines
1. Have you recently been experiencing any COVID-19 symptoms?
Yes, WITHIN the last 14 days
Yes, MORE THAN 14 days ago
No
Date started
Symptoms:
fever and/or chills
cough
difficulty breathing
body weakness
muscle pain
headache
loss of taste and/or smell
sore throat
nasal congestion
runny nose
nausea and/or vomiting
diarrhea
2. Have you been diagnosed with COVID-19 in the past?
Yes
No
3. Have you recently been exposed to someone who is a probable or confirmed COVID-19 case?
Yes, WITHIN the last 14 days
Yes, MORE THAN 14 days ago
No
Date of contact:
Place of known case
4. Have you recently returned from overseas travel?
Yes, WITHIN the last 14 days
Yes, MORE THAN 14 days ago
No
Date of arrival:
Country of exit
5. Need for travel abroad?
Yes
No
6. First day of last menstruation
Travel Destination
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Are you currently pregnant
Yes
No
Do you have allergies to medications, food, a vaccine component, or latex?
Yes
No
Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?
Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
Yes
No
Have you had a seizure or a brain or other nervous system problem?
Yes
No
Are you sick today?
Yes
No
Have you ever had a serious reaction after receiving a vaccination?
Yes
No
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?
Yes
No
Do you have a parent, brother, or sister with an immune system problem?
Yes
No
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
Yes
No
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
Yes
No
Have you received any vaccinations in the past 4 weeks?
Yes
No
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