RTHM New Patient Application

1
Please enter your e-mail.* This field is required.
example@example.com
2
What is your name?* This field is required.
First Name
Last Name
3
Are you located in the United States?* This field is required.RTHM can currently only serve patients in the United States
YESNO
4
Are you located in one of these US states?* This field is required.
Arizona
California
Colorado
Florida
New York
North Carolina
Oregon
Tennessee
Texas
Virginia
Washington
None of the above
Other
5
Which US state are you located in?
Alabama
Alaska
Arizona
Arkansas
California
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
6
Which country are you in?
Afghanistan
Akrotiri
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore and Cartier Islands
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Bassas da India
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Coral Sea Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Dhekelia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Europa Island
Falkland Islands (Islas Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Jan Mayen
Japan
Jersey
Jordan
Juan de Nova Island
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Namibia
Nauru
Navassa Island
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paracel Islands
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Spratly Islands
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands
Wake Island
Wallis and Futuna
West Bank
Western Sahara
Yemen
Zambia
Zimbabwe
7
Are you age 18 or older?* This field is required.
YESNO
8
Are you comfortable having medical conversations in English without a translator?
YESNO
9
Do you have or suspect you have at least one of these conditions: Long COVID, ME/CFS, COVID vaccine related illness, mast cell activation, dysautonomia (i.e. POTS or orthostatic hypotension), IBS, SIBO, Hashimotos thyroiditis, or hypothyroidism?
YESNO
10
Do you have a primary care doctor you've seen in the past 1 year?
YESNO
11
Do you/will you have active health insurance over the next 1 year period?
YESNO
12
Which insurance plan will you have over the next year?* This field is required.We found that Kaiser, Medicare, Medicaid/MediCal, VA/Tricare and several HMO insurance plans either require an in-network provider to order all the labs we request (and most of those providers either cannot or will not order everything we need), or the insurer ends up not paying for many of the labs we order and the patient gets a big surprise bill - which is awful! Thus we are not accepting patients with those insurance plans until we can figure out a better work around.
Kaiser Permanente
Medicaid or MediCal
VA or TRICARE
Oscar
Molina
Other health insurance plan
Medicare
13
Is your health insurance plan a PPO?* This field is required.
YESNO
14
Are you willing to track your medications/supplements and the severity of your symptoms nightly (should take less than 2 minutes using RTHM's system)?
YESNO
15
Are you willing to consent to having your data used for research purposes?* This field is required.
YESNO
16
Are you willing and/or able to leave your home for imaging, blood draws, or in-person exams/treatments when requested by a RTHM provider?* This field is required.
YESNO
17
Costs for your care and treatments are likely to exceed $1500/month, in some cases significantly so. Is this within your budget?* This field is required.For several of the conditions we treat, there are no FDA-approved treatments for them (everything is used off-label), so insurance often doesn't cover them despite submitting prior authorizations. Some lab testing is also not covered by insurance. We have worked with 3rd parties to get discounts for our patients on testing and treatments where we can, but we cannot control the prices other companies charge for their testing and treatments. One of RTHM's goals is to carefully collect data on what testing and treatments are highest yield for improving patients' health to ultimately try and get insurance coverage for them - hence our strong emphasis on data!
YESNO
18
Have you filled out our previous waitlist survey named "RTHM Long COVID & Post-Vax Waitlist" ?If Yes, we will search for your name in this waitlist to keep your place in line.
YESNO
19
What is your date of birth?* This field is required.
Date
Year
Month
Day
20
I am interested in: (Check all that apply)* This field is required.
Telehealth appointments through the RTHM Clinic
Participating in clinical trials associated with my condition
Receiving information regarding treatment, diagnostics, and latest research from RTHM and it's partners
21
For how long have you experienced symptoms of illness(es) you are seeking care at RTHM for?* This field is required.
1 - 2 months
2 - 6 months
6 - 12 months
More than 12 months
22
Please select the statement that best describes your level of physical function.* This field is required.
100: No symptoms at rest; no symptoms with exercise; normal overall activity level; able to work full-time without difficulty.
90: No symptoms at rest; mild symptoms with activity; normal overall activity level; able to work full-time without difficulty.
80: Mild symptoms at rest; symptoms worsened by exertion; minimal activity restriction noted for activities requiring exertion only; able to work full-time with difficulty in jobs requiring exertion.
70: Mild symptoms at rest; some daily activity limitation clearly noted. Overall functioning close to 90% of expected except for activities requiring exertion. Able to work full-time with difficulty.
60: Mild to moderate symptoms at rest; daily activity limitation clearly noted. Overall functioning 70%-90%. Unable to work full-time in jobs requiring physical labor, but able to work full-time in light activity if hours flexible.
50: Moderate symptoms at rest. Moderate to severe symptoms with exercise or activity; overall activity level reduced to 70% of expected. Unable to perform strenuous duties, but able to perform light duty or desk work 4-5 hours a day, but requires rest periods.
40: Moderate symptoms at rest. Moderate to severe symptoms with exercise or activity; overall activity level reduced to 50%-70% of expected. Not confined to house. Unable to perform strenuous duties; able to perform light duty or desk work 3-4 hours a day, but requires rest periods.
30: Moderate to severe symptoms at rest. Severe symptoms with any exercise; overall activity level reduced to 50% of expected. Usually confined to house. Unable to perform any strenuous tasks. Able to perform desk work 2-3 hours a day, but requires rest periods.
20: Moderate to severe symptoms at rest. Unable to perform strenuous activity; overall activity 30%-50% of expected. Unable to leave house except rarely; confined to bed most of day; unable to concentrate for more than 1 hour a day.
10: Severe symptoms at rest; bedridden the majority of the time. No travel outside of the house. Marked cognitive symptoms preventing concentration.
0: Severe symptoms on a continuous basis; bedridden constantly; unable to care for self.
23
Have you experienced any of the following issues in association with your illness(es)? (check all that apply):* This field is required.
Blood clots (DVT, pulmonary embolism, etc.)
Heart attack, heart failure, myocarditis, or pericarditis
Renal failure (requiring dialysis)
Acute respiratory distress syndrome (ARDS)
Guillain-Barré syndrome, Miller Fisher syndrome, transverse myelitis
Seizures, coma, stroke, and/or psychosis
None of the above
Other
24
Are you already established with any of the following specialists (check all that apply):* This field is required.
Neurologist
Rheumatologist
Gastroenterologist
Cardiologist
Pulmonologist
Hematologist
Pain management & rehabilitation (PM&R) or physiatrist
Psychiatrist
Mental health therapist
Physical therapist
Home health
Nutritionist or Dietician
Pain Management, Interventional Pain, or Anesthesia Pain specialist
None of the above
Other
25
If you don't already have a mental health care provider, would you be open to seeing one if your RTHM provider recommended it?* This field is required.
Yes
No
Unsure
I already have a mental health provider
26
Please select all of the wearable devices, health or fitness trackers that you have (that are not broken):* This field is required.
Fitbit
Apple Watch
Garmin watch
Polar watch, arm strap, or chest strap
Oura ring
Samsung or Galaxy smart watch
Biostrap wrist band
Whoop strap
None
Other
27
Do you wear a wearable health or fitness tracking device?* This field is required.
Yes, it's part of my daily routine
I don't wear one daily, but am willing to wear one daily if requested
I don't wear one daily, and realistically wouldn't wear one daily if I were asked to
I don't own one, but am willing to purchase one and wear it daily if requested
I don't own one and do not want to purchase one
Other
28
How often do you currently message, call or email your current healthcare providers on average?* This field is required.
Once per month or less
2-3 times per month
4-6 times per month
7-10 times per month
More than 10 times per month
29
The RTHM intake labs are extensive, and require several trips to only Quest Diagnostic Laboratories (or several mobile phlebotomy visits) to get the needed blood tests done. Are you willing and able to go for at least 3 separate blood draws from Quest in the first month as a RTHM patient?Due to the complexity of RTHM lab tests, we only order through Quest Diagnostics or through certain mobile phlebotomy companies. We cannot order labs through different medical facilities.
YESNO
30
Please write the name of a mobile phlebotomy service that is able to service your residence (or where you will be residing during your care with RTHM)? Examples are TRAVALAB.com, GetLabs.com, Sprinter Health, VeniExpress, or you can google "mobile phlebotomy near me" to find an alternative company and search to see if they serve your address.
If you cannot find a company that services your area, please write "None."
31
Please provide a brief overview of what health issues you are seeking care for at RTHM:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
32
How did you become aware of RTHM Clinic?
A provider or RTHM patient referred me
A friend, family member, or colleague referred me
Facebook post
Instagram post
Twitter post
News Article
Google search
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