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appl4e

patient intake form payload

appl4e
Apr 30th, 2025
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  1. {
  2.     "patient": {
  3.         "driving_lic_back": "data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAjgAAAFxCAYAAAB+ytLPAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAAEnQAABJ0Ad5mH3gAAP+lSURBVHhe7P0FvFbVtj6Oc44ddHd3d0mngIJiIAZ2oCIggoTSjQLSAiLd3d3dsbu7u/cGnv/zjHe/ng16z+F7r//P/X3uZy+dvPtd71pzzTnmiGeMOeZceZB75B65R+6Re+QeuUfu8X/syAU4uUfukXvkHrlH7pF7/J87cgFO7pF75B65R+6Re+Qe/+eOXICTe+QeuUfukXvkHrnH/7kjF+DkHrlH7pF75B65R+7xf+7IBTi5R+6Re+QeuUfukXv8nztyAU7ukX",
  4.         "driving_lic_front": "data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAjMAAAFtCAYAAADyPuvYAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAAEnQAABJ0Ad5mH3gAAP+lSURBVHhe7P0FnBzXtfYLyxDHjuPEzBSwkxyHE8cMkizZkm2Zme04dszMKNliZmkkjYaZmRl6erBpppkZpqd7enr4+Z5dihNJ0Ylzznvue+/5fip7qbqrqzauvdZ/7dpVMwdHt6Pb0e3odnQ7uh3djm7/i7ejMHN0O7od3Y5uR7ej29Htf/V2FGaObke3o9vR7eh2dDu6/a/ejsLM0e3odnQ7uh3djm5Ht//V21GYObod3Y5uR7ej29Ht6Pa/ejsKM0e3o9vR7e",
  5.         "zip_code": "75202",
  6.         "city": "Dallas",
  7.         "state": "Texas",
  8.         "address": "1412 Main St",
  9.         "gender": "male",
  10.         "dob": "04-03-2001",
  11.         "cell_phone": "6993495684",
  12.         "email": "[email protected]",
  13.         "first_name": "Mona",
  14.         "meeting_type": "Walk In"
  15.     },
  16.     "intake_form_data": {
  17.         "service_id": "2",
  18.         "2_past_treatment": {
  19.             "answer": "no",
  20.             "additional": {
  21.                 "prevResult": "",
  22.                 "furtherNeed": "",
  23.                 "reqTreatment": ""
  24.             }
  25.         },
  26.         "3_physician_care": {
  27.             "answer": "yes"
  28.         },
  29.         "5_last_year_dermatologist_care": {
  30.             "answer": "no"
  31.         },
  32.         "7_prescribed_medicines": {
  33.             "answer": "yes",
  34.             "medicines": [
  35.                 {
  36.                     "name": "Semaglee",
  37.                     "unit": "mg",
  38.                     "dosage_how_long": "2",
  39.                     "dosage": 10
  40.                 },
  41.                 {
  42.                     "name": "Tirzepetide",
  43.                     "unit": "mcg",
  44.                     "dosage_how_long": "3",
  45.                     "dosage": 25
  46.                 }
  47.             ]
  48.         },
  49.         "8_prescribed_allergy_medicines": {
  50.             "allergy": "yes",
  51.             "answer": "yes",
  52.             "allergy_details": "Worst",
  53.             "medicines": [
  54.                 {
  55.                     "name": "Tadalafil",
  56.                     "unit": "g",
  57.                     "dosage_how_long": "1",
  58.                     "dosage": 0.5
  59.                 },
  60.                 {
  61.                     "name": "Sildenafil",
  62.                     "unit": "mcg",
  63.                     "dosage_how_long": "4",
  64.                     "dosage": 50
  65.                 }
  66.             ]
  67.         },
  68.         "9_circulatory_respiratory": {
  69.             "checkValues": [
  70.                 "Hypoglycemic"
  71.             ]
  72.         },
  73.         "10_nervous_system": {
  74.             "checkValues": [
  75.                 "Paralysis"
  76.             ]
  77.         },
  78.         "11_digestive": {
  79.             "checkValues": [
  80.                 "Indigestion"
  81.             ]
  82.         },
  83.         "12_urinary_system": {
  84.             "checkValues": [
  85.                 "Heartburn"
  86.             ]
  87.         },
  88.         "13_history_other": {
  89.             "checkValues": [
  90.                 "Hypothyroidism",
  91.                 "Hyperthyroidism "
  92.             ]
  93.         },
  94.         "14_skin": {
  95.             "checkValues": [
  96.                 "Acne",
  97.                 "Cosmetic Surgery"
  98.             ]
  99.         },
  100.         "15_female_questions": {
  101.             "pregnant": "no",
  102.             "want_to_be_pregnant": "yes",
  103.             "breastfeeding": "no",
  104.             "taking_contraceptive": "yes"
  105.         },
  106.         "16_stress_items": {
  107.             "answer": "high",
  108.             "smoke_vape": "yes",
  109.             "alcohol": "sometime",
  110.             "recreational_drugs": "special occasions",
  111.             "caffeinated_product": "trying to quit",
  112.             "do_u_follow_specific_diet": "quit",
  113.             "specific_diet": [
  114.                 "Low Fat",
  115.                 "Keto"
  116.             ],
  117.             "daily_water_qty": "10 glass",
  118.             "surgical_history": "no"
  119.         },
  120.         "17_hygiene_cosmetics": {
  121.             "permanent_cosmetics": "yes",
  122.             "sun_block": "no",
  123.             "tanning_bed": "yes",
  124.             "tanning_cream": "no",
  125.             "aha_bha_scrub": "yes",
  126.             "isotretinoin_last_year": "no",
  127.             "cold_sores": "yes"
  128.         },
  129.         "18_usa_govt_identity": {
  130.             "selected_state": "Texas",
  131.             "id_number": "798789456456"
  132.         },
  133.         "4_dependent_provider_name": "Doctor Austin",
  134.         "signature": "data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAtEAAACgCAYAAADKKDBKAAAAAXNSR0IArs4c6QAAIABJREFUeF7tnQuYXFWV7/9rV3eHp0JM6nQgaBCQuUR5pKoSwqAkV0aEUQQlSOp0MNErDEFRGGWY102Y66cDKiAYBEZJTLoqSDuXl4Ki8xFnkECqKjycxKsiRiBQVQ0JCgrp7jrrsqurOpV3dXU9zqn+1zffNzF99nr81g69zq611xLw0xAC3e7Am0ggCT6FZQp04SIAESIAESIAESIIFAE2ASHejw0XgSIAESIAESIAESIIFWEPj/+NUh6/+FOgYAAAAASUVORK5CYII="
  135.     },
  136.     "schedule": {
  137.         "start": "03:30:00",
  138.         "end": "04:00:00",
  139.         "date": "04-30-2025"
  140.     },
  141.     "clinic": {
  142.         "id": "151"
  143.     }
  144. }
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