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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
*
-
Day
-
Month
Year
Ngày sinh
3b) Age Main - Hidden
4) Gender
*
Male
Female
5) Pre-existing medical conditions (check all that applies):
Cancer
Heart disease
COPD
Asthma
Diabetes
Obesity
None
Other conditions
5) Other conditions - Hidden
6) Did you have a confirmed positive Covid test or were diagnosed with Covid?
*
No
Yes
6b) (Yes) Please provide date:
*
-
Day
-
Month
Year
Date
7) Initial symptoms before HOCl treament (check all that applies):
*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Muscle Pains
Fatigue
Loss of taste or smell
Sore throat
Other symptoms
7) Other symptoms - Hidden
8) Symptoms started how many days before HOCl treatment?
*
9) HOCl treatment start date
*
-
Day
-
Month
Year
Date
9b) How many days did you use HOCl?
*
10) SpO2 level prior to HOCl treatment (if known):
11) HOCl treatment modality
*
Rows
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?
*
Yes
No
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?
*
Yes
No
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):
*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Muscle Pains
Fatigue
Loss of taste or smell
Sore throat
Other symptoms
14) Did you get a confirmed negative Covid test?
No, not yet
Yes
14b) (Yes) Please provide date of negative test.
*
-
Day
-
Month
Year
Date
15) Did you have to stop HOCl treatment because of negative side-effects?
*
No
Yes
15b) (Yes) Please provide reason.
*
16) Did you use oxygen supplement at anytime during your HOCl treatment?
*
No
Yes
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)
Hydroxychloroquine
Ivermectin
Corticosteroids (i.e., prednisone, methylprednisolone tablets, or budesonide inhalation, etc.)
Antibiotic
Vitamin D
None, I did not take any other medications
Other medications
17) Other medications - Hidden
18) Did you seek additional medical treatment?
*
Doctor's office visit
Hospital ER visit
Hospitalized
No, 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
-
Day
-
Month
Year
Current Date
Hidden Count
Country - hidden
Lang - hidden
Verification Notes - Hidden
Severity - hidden
Submit
Should be Empty: