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appl4e

Intake form update payload

appl4e
May 23rd, 2025
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  1. {
  2.     "patient": {
  3.         "zip_code": "32824",
  4.         "city": "Orlando",
  5.         "state": "Florida",
  6.         "address": "12340 Boggy Creek Rd",
  7.         "gender": "male",
  8.         "dob": "01-06-2000",
  9.         "cell_phone": "3312762635",
  10.         "email": "[email protected]",
  11.         "first_name": "Linus 4",
  12.         "meeting_type": "Walk In"
  13.     },
  14.     "intake_form_data": {
  15.         "signature": "",
  16.         "18_usa_govt_identity": {
  17.             "selected_state": "Texas",
  18.             "id_number": "1234"
  19.         },
  20.         "17_hygiene_cosmetics": {
  21.             "permanent_cosmetics": "yes",
  22.             "sun_block": "yes",
  23.             "tanning_bed": "yes",
  24.             "tanning_cream": "yes",
  25.             "aha_bha_scrub": "yes",
  26.             "isotretinoin_last_year": "yes",
  27.             "cold_sores": "yes"
  28.         },
  29.         "16_stress_items": {
  30.             "answer": "Moderate",
  31.             "smoke_vape": "yes",
  32.             "alcohol": "sometime",
  33.             "recreational_drugs": "special occasions",
  34.             "caffeinated_product": "trying to quit",
  35.             "do_u_follow_specific_diet": "quit",
  36.             "specific_diet": [
  37.                 "Healthy",
  38.                 "Other"
  39.             ],
  40.             "daily_water_qty": "8 to 16 ounces (1-2 cups)",
  41.             "surgical_history": "None"
  42.         },
  43.         "15_female_questions": {
  44.             "pregnant": "yes",
  45.             "want_to_be_pregnant": "yes",
  46.             "breastfeeding": "yes",
  47.             "taking_contraceptive": "I need contraceptive, help me."
  48.         },
  49.         "14_skin": {
  50.             "checkValues": [
  51.                 "Psoriasis",
  52.                 "other"
  53.             ],
  54.             "others": "Test 18"
  55.         },
  56.         "13_history_other": {
  57.             "checkValues": [
  58.                 "Diabetes Type 1",
  59.                 "other"
  60.             ],
  61.             "others": "test 12"
  62.         },
  63.         "12_urinary_system": {
  64.             "checkValues": [
  65.                 "Liver Disease",
  66.                 "other"
  67.             ],
  68.             "others": "test 10"
  69.         },
  70.         "11_digestive": {
  71.             "checkValues": [
  72.                 "other",
  73.                 "Ulcer"
  74.             ],
  75.             "others": "Test 69"
  76.         },
  77.         "10_nervous_system": {
  78.             "checkValues": [
  79.                 "Chronic Pain",
  80.                 "other"
  81.             ],
  82.             "others": "Test 10"
  83.         },
  84.         "9_circulatory_respiratory": {
  85.             "checkValues": [
  86.                 "Asthma",
  87.                 "other",
  88.                 "Allergies"
  89.             ],
  90.             "others": "Test 9"
  91.         },
  92.         "8_prescribed_allergy_medicines": {
  93.             "answer": "yes",
  94.             "medicines": [
  95.                 {
  96.                     "dosage_how_long": "10 days",
  97.                     "dosage_unknown": "false",
  98.                     "unit": "mg",
  99.                     "dosage": "250",
  100.                     "name": "Y"
  101.                 }
  102.             ],
  103.             "allergy": "yes",
  104.             "allergy_details": "Skin"
  105.         },
  106.         "7_prescribed_medicines": {
  107.             "answer": "yes",
  108.             "medicines": [
  109.                 {
  110.                     "dosage_how_long": "50 days",
  111.                     "dosage_unknown": "false",
  112.                     "unit": "mcg",
  113.                     "dosage": "500",
  114.                     "name": "Napa"
  115.                 },
  116.                 {
  117.                     "name": "X",
  118.                     "unit": "mg",
  119.                     "dosage": "",
  120.                     "dosage_unknown": "unknown",
  121.                     "dosage_how_long": "30 days"
  122.                 }
  123.             ]
  124.         },
  125.         "5_last_year_dermatologist_care": {
  126.             "answer": "yes"
  127.         },
  128.         "6_dependent_provider_name": "Test 5",
  129.         "3_physician_care": {
  130.             "answer": "yes"
  131.         },
  132.         "4_dependent_provider_name": "Test 4",
  133.         "2_past_treatment": {
  134.             "answer": "yes",
  135.             "additional": {
  136.                 "prevResult": "Test 1",
  137.                 "furtherNeed": "Test 2",
  138.                 "reqTreatment": "Test 3"
  139.             }
  140.         },
  141.         "service_ids": [
  142.             "2",
  143.             "6",
  144.             "28",
  145.             "12",
  146.             "20"
  147.         ],
  148.         "1_service_info": {
  149.             "height_feet": "5",
  150.             "height_inch": "6",
  151.             "weight": "175",
  152.             "bmi": "79",
  153.             "ideal_weight": "159"
  154.         }
  155.     },
  156.     "docu_spa_service_u_id": "68300081bd61b"
  157. }
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