COVID-19 PDT Initial Questionnaire

Health and Medical History
Height*
Height in feet and inches
Weight*
Weight in pounds
Name of your doctor or clinic (you may indicate - NONE)*
Have you had a CoVID-19 test within the past 2 weeks?*

YesNo
CoVID-19 test result*

Negative - Rapid Antigen onlyNegative - PCR onlyNegative - both Rapid Antigen and PCRPositive - Rapid Antigen onlyPositive - PCR onlyPositive - both Rapid Antigen and PCR
Please upload a copy of your test results

Cancelof
Have you had a CoVID-19 vaccine?

YesNo
Which vaccine have you received:

Astra ZenecaPfizerModernaJohnson and JohnsonOther
Date of first shot

MonthDayYear
Date
Date of second shot (if applicable)

MonthDayYear
Date
Date of third shot (if applicable)

MonthDayYear
Date
Date of fourth shot (if applicable)

MonthDayYear
Date
Have you had ANY recent symptoms that may suggest CoVID-19? Please answer yes even if you think the symptoms may be due to another cause, e.g. sinusitis

YesNo
When did you notice your first symptoms - PLEASE answer this question as accurately as you can. This is very important to determine which treatment may be best for you.*

MonthDayYear
Date
Do you have any known allergies?*

YesNo
Please list any known allergies
Please check any medical conditions or risk factors. Please think carefully and indicate previous and ongoing medical issues. This can significantly impact your response to CoVID-19 so it is important to provide ACCURATE and COMPLETE information so we can advise your properly.*

DiabetesHigh Blood PressureKidney DideaseHeart DiseaseAsthma or Lung DiseaseLiver DiseaseImmune compromisedCancerSmokerPregnant/BreastfeedingAnemiaMigraine HeadachesOver 65NONE KNOWNOther
Please list your regular medications. This is very important.
Please list ALL treatments used since the onset of your symptoms including prescription and non-prescription treatments or supplements.
Have you been previously diagnosed with COVID-19?*

YesNo
Please provide further details (date of diagnosis, were you hospitalized or not, treatment, etc.)
Are your symptoms*

WorseningGetting betterNot changing

Do you currently have diarrhea?

YesNo
How many bouts of diarrhea per day?

1-2 slightly loose stools per day1-3 bouts of diarhea4-6 bouts of diarrhea7-10 bouts of diarrheaMore than 10 bouts of diarrhea
Please describe in as much detail as possible how you symptoms have progressed since the onset.
Do you have a pulse oximeter at home? (Note: this is advisable for all households).*

YesNo
Please indicate your current oxygen saturation reading.*
Please indicate your current heart rate reading.*
Do you have a reliable thermometer at home? (Note: this is advisable for all households).*

YesNo
Please indicate your current temperature.*

Household
Please note that ALL members of your household should be treated t the same time if there you have had a high risk exposure or if you have CoVID-19 infection.
How many persons in your household? *
Do any members of your household have any of the CoVID-19 symptoms above?*

YesNo
Please indicate the (1) ages of anyone in your household that has symptoms, (2) what symptoms they are experiencing and (3) when the symptoms started:*

I hereby declare that all the given information is accurate. I understand that failure to provide complete and accurate information may significantly compromise the success of my treatment.
Should be Empty:

	Absent	Very Mild	Mild	Moderate	Severe
Loss of taste or smell
Difficulty breathing
Runny nose/nasal congestion
Cough
Headache
Chills
Abdominal Pain
Diarrhea
High fever
Sore throat
Body aches
Persistent pain or pressure on chest
Fatigue
Nausea/vomiting

COVID-19 PDT Questionnaire

Health and Medical History

Household