HOCl Treatment Questionnaire

HOCl Treatment Questionnaire

Please help us as we are trying to gather data on the effectiveness of Hypochlorous Acid (HOCl) in the treatment of mild to severe symptoms of Covid-19. If you have used our HOCl solution, we ask if you could help us fill out this short questionnaire. We strive to be as precise as possible with the questions, but if you have any questions, please let us know in the comment section at the end of the questionnaire. We appreciate your time and effort. Your personal data is kept confidential and our secure system is HIPAA compliant.
All fields marked with * are required and must be filled.
Order Number - Hidden
1) Full Name (First and Last) *
2) Contact information*
Email
3) Age*
3) Ngày sinh*

DayMonthYear
Ngày sinh
3b) Age Main - Hidden
4) Gender*

MaleFemale
5) Pre-existing medical conditions (check all that applies):

CancerHeart diseaseCOPDAsthmaDiabetesObesityNoneOther conditions
5) Other conditions - Hidden
6) Did you have a confirmed positive Covid test or were diagnosed with Covid?*

NoYes
6b) (Yes) Please provide date:*

DayMonthYear
Date
7) Initial symptoms before HOCl treament (check all that applies):*

FeverCoughShortness of Breath / Difficulty BreathingMuscle PainsFatigueLoss of taste or smellSore throatOther symptoms
7) Other symptoms - Hidden
8) Symptoms started how many days before HOCl treatment?*
9) HOCl treatment start date*

DayMonthYear
Date
9b) How many days did you use HOCl?*
10) SpO2 level prior to HOCl treatment (if known):

11) HOCl treatment modality *

	1 time / day	2 times / day	3 or more times / day	Did not use
Nebulizer
Nano Mister
Room humidifier
Nasal rinse
Mouth gargle

11b) Modality Code - Hidden
12) Did you notice a significant improvement of your symptoms after using HOCl?*

YesNo
12b) How many days after the start of HOCl did you notice the improvement?*
13) Did all your symptoms completely resolve and go away after using HOCl?*

YesNo
13b) How many days did it take for your symptoms to be completely resolved?*
13c) Symptom or symptoms still persisting after using HOCl (check all that applies):*

FeverCoughShortness of Breath / Difficulty BreathingMuscle PainsFatigueLoss of taste or smellSore throatOther symptoms
14) Did you get a confirmed negative Covid test?

No, not yetYes
14b) (Yes) Please provide date of negative test.*

DayMonthYear
Date
15) Did you have to stop HOCl treatment because of negative side-effects?*

NoYes
15b) (Yes) Please provide reason.*
16) Did you use oxygen supplement at anytime during your HOCl treatment?*

NoYes
16b) (Yes) For how many days?*
17) Did you take any of the following medications during the time of HOCl treatment? (check all that applies)

HydroxychloroquineIvermectinCorticosteroids (i.e., prednisone, methylprednisolone tablets, or budesonide inhalation, etc.)AntibioticVitamin DNone, I did not take any other medicationsOther medications
17) Other medications - Hidden
18) Did you seek additional medical treatment?*

Doctor's office visitHospital ER visitHospitalizedNo, did not seek additional medical treatment
19) Additional Comments:
Translated Comments - hidden
20) How did you find out about our HOCl product?
Current Date - Hidden

DayMonthYear
Current Date
Hidden Count
Country - hidden
Lang - hidden
Verification Notes - Hidden
Severity - hidden

Should be Empty: