Post Viral / Post Vaccination Symptoms
Initial Questionnaire
Name
*
First Name
Middle Initial
Last Name
Birth Date
*
-
Day
-
Month
Year
Date
Gender
*
Female
Male
Email
*
example@example.com
Reason for seeking assistance
Persistent symptoms after viral infection (e.g. Long Covid)
Persistent symptoms after CoVID-19 vaccination
Persistent symptoms after CoVID-19 vaccination PLUS persistent symptoms after viral infection
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Second Phone Number (relative)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
*
Please provide directions to your house in case delivery is required or type N/A
*
Name of you Care Provider
Capriata Health and Wellness
Dr. Forrestall Dorsett
Nurse Catriona McTaggart
Luminnova Health
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Medical History
Height
*
Height in feet and inches
Weight
*
Weight in pounds
Name of your doctor or clinic (you may indicate - NONE)
*
Have you OR a member of your household had a CoVID-19 test within the past 2 weeks?
*
Yes
No
CoVID-19 test result
*
Negative - Rapid Antigen only
Negative - PCR only
Negative - both Rapid Antigen and PCR
Positive - Rapid Antigen only
Positive - PCR only
Positive - both Rapid Antigen and PCR
Have you had a CoVID-19 vaccine?
Yes
No
Which vaccine have you received:
Astra Zeneca
Pfizer
Moderna
Johnson and Johnson
Other
Date of first shot
-
Month
-
Day
Year
Date
Date of second shot (if applicable)
-
Month
-
Day
Year
Date
Date of third shot (if applicable)
-
Month
-
Day
Year
Date
Date of fourth shot (if applicable)
-
Month
-
Day
Year
Date
When did you first notice your current symptoms - PLEASE answer this question as accurately as you can.
*
-
Month
-
Day
Year
Date
Do you have any known allergies?
*
Yes
No
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 and other viral illnesses so it is important to provide ACCURATE and COMPLETE information so we can advise your properly.
*
Diabetes
High Blood Pressure
Kidney Didease
Heart Disease
Asthma or Lung Disease
Liver Disease
Immune compromised
Cancer
Smoker
Pregnant/Breastfeeding
Anemia
Migraine Headaches
Over 65
NONE KNOWN
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?
*
Yes
No
Please provide further details (date of diagnosis, were you hospitalized or not, treatment, etc.)
Are your symptoms
*
Worsening
Getting better
Not changing
Please indicate your current symptoms so your response to treatment can be assessed.
*
Rows
Absent
Very Mild
Mild
Moderate
Severe
Fatigue
Symptoms worsen after physical or mental exertion
“Brain fog” / Memory problems
Tremor
Dizziness
Headache
Sleep disturbance
Anxiety/depression
“Pins and needles”/numbness
Chest pain
Chest tightness
Palpitations
Difficulty breathing / Shortness of breath
Persistent Cough
Nausea
Diarrhea
Abdominal pain
Tinnitus
Earache
Sore throat
Feeling of pressure in the head
Joint pain/Muscle or Other pain
Skin symptoms
Please indicate if you have any symptoms not listed above
If you have shortness of breath or difficulty breathing please indicate your current oxygen saturation reading. If not you may answer: N/A
*
If you have experienced palpitations indicate your current heart rate reading. If not you may answer: N/A
*
If you have a fever please indicate your current temperature. If not you may answer: N/A
*
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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.
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