Sept/Version A+B - Symptom qx

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Please enter your first and last name so we can save your entries:*

First NameLast Name
Name - Passed by Reg form

First NameLast Name
Please enter your date of birth so we can match it to your information on file.*

MonthDayYear
Date of Birth
AGE
You can't enter a birth date more than 120 years ago, since we're pretty sure there is no one alive that old. Please double check and correct your birthdate.
Given your age, Dr. Haider usually recommends an extended high-risk protocol which includes dutasteride and spironolactone (for those patients who are not already on them and don't have any other contraindications), which are thought to help with acute and long COVID, especially in higher-risk men, but also in higher-risk women. Dutasteride is commonly used for enlarged prostate and hair loss in men and spironolactone is commonly used in both sexes for high blood pressure, or as a water pill, and in women for acne.

Both are androgen blockers which can interfere with fetal development, so should not be handled by women of childbearing age (unless they are on strict birth control or otherwise certain they are not and cannot get pregnant), should any women of that description be in the household.

Spironolactone is a potassium-sparing diuretic (water pill), which means that it may raise your body's levels of potassium. If you do not take a potassium supplement and you have normal functioning kidneys then your body can usually handle this and remove any excess potassium. However, if you do take potassium supplementation (often recommended to patients who have chronically low levels due to other diuretics/water pills), and/or if you have low kidney function, then you may develop excessively high levels of potassium when you add spironolactone, which can be dangerous and cause heart arrhythmias in rare cases. It is always recommended to get potassium levels checked a week after starting on spironolactone.

If you would like Dr. Haider to consider one or both of these meds for your protocol in case of developing an acute COVID infection, let us know that you have read the above and would like them added to your prescriptions. *
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DOB - Passed by Reg From

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Date of Birth
Please enter your current weight for our records and for proper medication dosing:
Please enter your current weight for our records and for proper medication dosing:
KGs
Please enter your current weight for our records and for proper medication dosing:*
Lbs
yesno
Please enter your Blood Pressure in the format: larger number / smaller number:*
What date was this Blood Pressure taken?*

MonthDayYear
Date
yesno
Please enter your heart rate: *
What date was this heart rate taken?*

MonthDayYear
Date
Please enter your email for verification.*
example@example.com
Please enter your email for verification. (Passed from reg form)
example@example.com
Please provide a good phone number in case Dr. Haider needs to reach you:*

Area CodePhone Number
yesno
yesno
Please enter the date of your latest vaccination:*

MonthDayYear
Date
Which covid-19 vaccination did you get?*
yesno
Please enter the date it was last checked:*

MonthDayYear
Date
Please enter the value of the D-dimer:*
Please attach the results:*

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Cancelof
yesno
Please enter the date of your latest positive test result:*

MonthDayYear
Date
Rapid antigen testPCR testNot sureOther
Yes, someone I live with has COVID-19Yes, within arm's reach of someone diagnosed with COVID-19 for 8 or more hours this weekYes, someone I've been around has been diagnosed with COVID-19No, I haven't been in direct contact with anyone diagnosed with COVID-19
Yes, someone I live with has influenzaYes, within arm's reach of someone diagnosed with influenza for 8 or more hours this weekYes, someone I've been around has been diagnosed with influenzaNo, I haven't been in direct contact with anyone diagnosed with influenza
Yes, someone I live with has RSVYes, within arm's reach of someone diagnosed with RSV for 8 or more hours this weekYes, someone I've been around has been diagnosed with RSVNo, I haven't been in direct contact with anyone diagnosed with RSV
yesno
The following questions will help the medical team determine the initial symptoms' severity and monitor symptom changes/effects of treatment over time. Your treatment will depend on the severity of the symptoms and the doctor's criteria.
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Tell us about your problem:*
When did this problem start?*

MonthDayYear
Date
You cannot enter a date earlier than your date of birth.
Current Date

MonthDayYear
Date
Number of days since the problem started
yesno
When did it worsen?*

MonthDayYear
Date
You must enter a date after the problem started.
yesno
painOther
Where do you feel the most pain?*
yesno
Where does the pain radiate?*

sharpstabbingheavinesspressuresqueezingachingOther
Which part of your body is most affected by this problem?*
Please be as specific as possible including descriptors like right / left, upper /lower, inner / outer, etc
yesno
What other body parts are affected?*
mildmoderatesevere
yesno
When was it last checked?*

MonthDayYear
Date
Please enter your latest oxygen level:*
General: e.g. fever, chills, appetite change, weight change, etc.Head & Neck: e.g. headache, symptoms in the: eyes, ears, nose, throat, etc.Heart & Blood Vessels: e.g. chest pain, swollen legs, racing heart, skipped beats, varicose veins, etc.Chest & Lungs: e.g. cough, shortness of breath, wheeze, tightness, etc.Digestion: e.g. pain, reflux, gas, bloating, constipation, diarrhea, hemorrhoids, bloody stool, black stool etc.Urinary: e.g. burning, frequency, discharge, blood, etc.Muscles, Bones & Joints: e.g. back/neck pain, joint pain, swelling, heat, redness, etc.Brain & Nervous System: e.g. confusion, dizziness, passed out, nerve pain, numbness, tingling, loss of function.Hair & Skin: e.g. rashes, itching, acne, sores, bruises, hair loss/thinning, etc.Hormonal: e.g. hot flashes, night sweats, etc.Gynecological: e.g. period pain, heavy periods, no period, abnormal bleeding, etc.Sexual: e.g. no desire, unable to perform, rash, sores, etc.OtherNone of these
feverchillsless appetitemore appetiteweight lossweight gainnone of theseOther
headachered eyeseye painitchy eyesear painhearing lossdischarge from earrunny nosestuffy nosenose bleedsore throathard to swallownone of theseOther
Describe your headaches:*

Which part of your head hurts?*
worst headache of my lifedifferent than any headache I've every hadhappened after traumachange in visionnone of these
This is a common complaint with COVID, but is also a red flag for telemedicine meaning we have no choice but to refer you to an in person evaluation to make sure you don't have a serious condition like a stroke or aneurysm. Please consult the nearest ER or Urgent care out of caution for a neurological screening exam. Continuing with this visit indicates that you relieve us of any liability should we misdiagnose your condition due to the inherent limitations of telemedicine.*
Describe the trauma and when it happened:*
Describe the change in vision:*
Hard to swallow? Tell us more:*
chest painswollen legsracing heartskipped beatsvaricose veinsnone of theseOther
The chest pain needs to be worked up in person either ER or urgent care, it can be caused by muscles, but could also be a sign of bacterial superinfection/pneumonia, pulmonary embolism (blood clot in lungs), heart attack, rupture of lung tissue causing air leak into the chest cavity, dissection of the aorta, etc. Continuing with this visit indicates that you relieve us of any liability should we misdiagnose your condition due to the inherent limitations of telemedicine.*
coughshortness of breathwheezingchest tightnesschest painhurts to breath inrapid breathingnone of theseOther
yesno
Tell us more about the blood:*
Coughing up blood can be a sign of a broken blood vessel from heavy coughing, nosebleed dripping into the throat, pneumonia or blood clots in the lungs. Blood clots are a common complication of COVID, are diagnosed by CT scan with contrast and need treatment with injection blood thinners. Continuing with this visit indicates that you relieve us of any liability should we misdiagnose your condition due to the inherent limitations of telemedicine.*
The chest pain needs to be worked up in person either ER or urgent care, it can be caused by muscles, but could also be a sign of bacterial superinfection/pneumonia, pulmonary embolism (blood clot in lungs), heart attack, rupture of lung tissue causing air leak into the chest cavity, dissection of the aorta, etc. Continuing with this visit indicates that you relieve us of any liability should we misdiagnose your condition due to the inherent limitations of telemedicine.*
Rapid breathing is usually a sign of dropping oxygen levels and usually indicates that you have a serious underlying lung problem like pnuemonia or a blodo clot and need to be worked up in an urgent care or ER. Your body can get tired if this goes on too long and it can usually be reversed by getting some additional oxygen through a nasal cannula. Continuing with this visit indicates that you relieve us of any liability should we misdiagnose your condition due to the inherent limitations of telemedicine.*
stomach painacid refluxgasbloatingconstipationdiarrheahemorrhoidsbloody stoolblack stoolnone of theseOther
Where is the stomach pain and how bad is it?*
Stomach pain can be a sign of just gas, constipation or too much acidity in the stomach, but can also be more serious and if severe needs to be worked up in person. Continuing with this visit indicates that you relieve us of any liability should we misdiagnose your condition due to the inherent limitations of telemedicine.*
How often do you have diarrhea?*
Are the hemorrhoids bleeding?*
Tell us about the bloody stool: *
Tell us about the black stool: *
burning urinefrequent urinationblood in urinekidney stonesdischargebladder painnone of theseOther
back painneck painjoint painswellingheatrednessnone of theseOther
Joint pain: which joints?*
Where is the swelling?*
Where does it feel hot?*
Where is it red?*
confusiondizzinesspassed outnerve painnumbnesstinglingloss of functionheadachenone of theseOther
Where is the nerve pain?*
Where is the numbness?*
Where is the tingling?*
What function(s) have you lost?*
Describe your headaches:*
rashesitchingacnesoresbruiseshair loss/thinningnone of theseOther
Where are the rashes?*
Where is the itching?*
Where is the acne?*
Where are the sores?*
Where are the bruises?*
Where is the hair loss or thinning? *
hot flashesnight sweatsnone of theseOther
period painheavy periodsno periodabnormal bleedingnone of theseOther
no desireunable to performrashsoresdischargenone of theseOther
What other symptoms are you having?*
yesno
What symptoms did you have before that you no longer have?*
getting worsegetting betterstaying the same
yes, some things make it worseyes, some things make it betterno
What makes it worse?*
What makes it better?*
What treatments are you currently using for this and how are they working?*
IvermectinHydroxychloroquineFluvoxamineFluoxetineBudesonide inhalerPravastatinPrednisoneVascepaLow dose naltrexoneOtherNone
What dose of Ivermectin are you taking?*
When did you start taking Ivermectin?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Hydroxychloroquine are you taking?*
When did you start taking Hydroxychloroquine?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Fluvoxamine are you taking?*
When did you start taking Fluvoxamine?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Fluoxetine are you taking?*
When did you start taking Fluoxetine?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Budesonide inhaler are you taking?*
When did you start taking Budesonide inhaler?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Pravastatin are you taking?*
When did you start taking Pravastatin?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Prednisone are you taking?*
When did you start taking Prednisone?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Vascepa are you taking?*
When did you start taking Vascepa?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
What dose of Low dose naltrexone are you taking?*
When did you start taking Low dose naltrexone?*

MonthDayYear
Date
yesno
Please explain which symptom and how it changed:*
Please list each medication along with the dose and when you started taking it:*
yesno
Which treatments would you like to avoid?*
Why would you like to avoid the listed treatment(s)?*
yesno
Tell us which treatments you stopped and why:*
suddenlygraduallyOther
yesnoOther
What do you think triggered or caused these symptoms?*
past medical historyinjuriesproceduressurgeriesdietenvironmental exposurespersonal care productsallergiesdaily activitieshabitsrecreational drugssmokingalcohol usesports activitiesworkplace environmenthome environmentOther
Which past medical issues?*
Which injuries and when were they?*
Which procedures and when were they?*
Which surgeries and when were they?*
Which dietary items?*
Which exposures?*
Which products?*
Which allergies?*
Which activities?*
Which habits?*
Which drugs?*
Tell us more about your smoking:*
Tell us more about your alcohol use:*
What sports activities?*
What about your workplace?*
What about your home environment?*
yesno
Which relatives?*
yesno
When did you last see a provider for these symptoms?*

MonthDayYear
Date
You must enter a date after the problem started.
Who most recently treated you and/or where were you treated?*
yesno
What tests were done and what were the results?*
yesno
List all diagnoses from the most recent visit:*
What was the treatment during this recent visit and how did it go?*
Be as specific as possible and include names/doses of any meds prescribed.
yesno
When is your follow-up scheduled:*

MonthDayYear
Date
What are you hoping to get from this virtual visit today that can’t wait until your follow-up visit?*
Tell us why you decided not to follow up with the last provider you saw:*
yesnomaybedon’t know
yesno
How frequently do you get the same or similar symptoms?*
more frequentlyless frequentlyno change or same as always
Tell us more about the increased frequency:
Tell us more about the decreased frequency:
yesno
What diagnoses have you received in the past?*
yesno
What tests have been done in the past and what were the results?*
yesno
Which treatments worked well before?*
yesno
Which treatments didn’t work well before?*
yesno
What else would you like Dr. Haider to know about this?*
yesno
What is the first day you would like to take off from work?*

MonthDayYear
Date
The first day requested off work can't be before the illness began.
What is the last day you would like off from work?*

MonthDayYear
Date
Your last day requested away from work can't be before the first day you request away from work.
When would you like to return to work?*

MonthDayYear
Date
The day you would like to return to work has to be after the last day you take off from work.
If there is something visible that a doctor in-person would normally look at and it can be photographed, then please take a clear, focused, bright photo of it now and upload it here. You can also upload any relevant medical records, images, videos, labs, or pathology reports you think Dr. Haider might need to review for this request.

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Symptom Questionnaire