COVID-19/URTI Defense Questionnaire
Name
*
First Name
Middle Initial
Last Name
Birth Date
*
-
Day
-
Month
Year
Date
Gender
*
Female
Male
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name of Care Provider
Luminnova Health
Dr. Forrestall Dorsett
Nurse Catriona McTaggart
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Health and Medical History
Height
*
Height in feet and inches
Weight
*
Weight in pounds
Name of your doctor or clinic (you may indicate - NONE)
*
Have you had a CoVID-19 vaccine?
Yes
No
How many CoVID-19 vaccines have you received?
One
Two
Three
Four
Five
Six
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
Have you been previously diagnosed with COVID-19?
*
Yes
No
Were you diagnosed with CoVID-19 prior to your initial vaccine dose?
*
Yes
No
Have you had ANY recent symptoms that may suggest CoVID-19? Please answer yes even if you think the symptoms may be due to another cause, e.g. sinusitis
Yes
No
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.
*
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.
Do you have any known allergies?
*
Yes
No
Please list any known allergies
Have you had your vitamin D level tested?
*
Yes
No
Please indicate your most recent vitamin D test results.
*
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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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