Luminnova Health CovidCare Registration

Health and Medical History
Height
Height in feet and inches
Weight
Weight in pounds
Name of your primary care doctor or clinic (you may indicate - NONE)
Have you had a CoVID-19 test within the past 2 weeks?
CoVID-19 test result
Please upload a copy of your test results - research study participants MUST do so

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Have you had a CoVID-19 vaccine?
Which vaccine have you received:

Other
Date of first shot

MonthDayYear
Date
Date of second shot (if applicable)

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

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

Please indicate your current symptoms if any. Please rate the severity of your symptoms on a 0-5 scale with 0=absent, 1=Very mild, 2=mild, 3=moderate, 4=severe and 5=extreme.

Rows	0	1	2	3	4	5
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
Earache
Night sweats

Have you had any diarrhea?
If you do have diarrhea, many bouts of diarrhea per day?
Please provide additional details for the symptom ratings given above and describe in you own words how your symptoms have progressed compared to your initial symptoms.
Do you have a pulse oximeter at home? (Note: this is advisable for all households).
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).
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?
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:

CovidCare System Registration

Health and Medical History

Household