PMV Coaching Health Questionnaire

Health Questionnaire

Please complete this form before your coaching session. Your answers will help to guide our discussions. Feel free to repeat the form any time.
Today's Date

MonthDayYear
Date
Identification*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of COVID-19 Diagnosis

MonthDayYear
Date
Approximate Date Symptoms Began:

MonthDayYear
Date
Gender

MaleFemaleN/A
Date of Birth

MonthDayYear
Date

Long COVID is a cluster of new symptoms that may seem unrelated and are hard to explain or manage without medical intervention.

Long COVID typically involves multiorgan effects or autoimmune conditions with symptoms lasting weeks, months, or even years after COVID-19 illness or the vaccine.

Clinical evaluations and results of routine blood tests, chest X-rays, and electrocardiograms may be normal, making it difficult to find answers and solutions.
How long have you had this concern?
Enter time period ( days, months)
Long COVID is a cluster of new symptoms that may seem unrelated and are hard to explain or manage without medical intervention. Long COVID typically involves multiorgan effects or autoimmune conditions with symptoms lasting weeks, months, or even years after COVID-19 illness or the vaccine. If you have 3 or more of the conditions listed in this screening tool, you most likely have Long COVID or another post viral syndrome. Clinical evaluations and results of routine blood tests, chest X-rays, and electrocardiograms may be normal, making it difficult to find answers and solutions. Need support? Nurse Laney's team of Long COVID Health Coaches and Disability Advocates are here to help. Visit www.promedview.com to learn about our services and book a session.
Are you taking any medications?

YesNo

Please add any other health related Issues you might want to discuss during session
Upload any Pictures or Videos you feel might be relevant in your health review:

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Do you agree a LONG COVID Health Coaching program can assist in your recovery?*

YesNo
Should be Empty:

	YES	NO	NA
Tiredness or fatigue that interferes with daily life
Symptoms that get worse after physical or mental effort (also known as “post-exertional malaise”)
Fever without obvious infection
Hair loss/shedding
Deformed or discolored finger or toe nails
New food allergies/sensitivities

	YES	NO	NA
Difficulty breathing or shortness of breath
Cough
Chest pain
Fast-beating or pounding heart (also known as heart palpitations)
Low oxygen levels

	YES	NO	NA
Headache
Sleep problems
Dizziness when you stand up (lightheadedness)
Pins-and-needles feelings
Change in smell or taste
Seizures
Internal vibrations
Twitching
Ticks
Muscle spasms / Twitching
Neuropathy (nerve pain)
Muscle weakness
False messages from nerves - Pain without injury, shortness of breath but normal oxygen saturation levels (97%+), hunger after eating, sense of fullness without eating
Parkinson like shaking
Cognitive changes, brain fog
Dementia like forgetfulness or confusion
Depression
Anxiety
Other psychiatric issues i.e. OCD, paranoia, agoraphobia, etc.
Brain Fog: Difficulty concentrating or focusing
Internal vibrations or shaking

	YES	NO	NA
Pain
Rash
Mottled/Discolored skin
Changes in menstrual cycles
Erectile issues
Post exertion fatigue/inflammation
Exercise intolerance
Heat or cold intolerance

	YES	NO	NA
Diabetes
Heart conditions
Blood clots
Diagnosed clotting disorders such as Factor V
Hypertension (high blood pressure)
Hypothyroid (under active)
Hyperthyroid (over active)
Lupus
Multiple Sclerosis
Dysautonomia
Immunocompromise
Myalgic encelphalomyelitis (ME)/Chronic fatigue syndrome (CFS)
Reactivated viruses (Lyme, Epstein Barr, Shingles, etc.)
Organ failure
Bleeding disorders