Health Screening Questionnaire
Initial
Name
*
First Name
Middle Initial
Last Name
Birth Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender
*
Female
Male
Email
*
example@example.com
Reason for seeking assistance
*
General wellness
Recovery from medical illness/surgery
Long Covid/Post Vax
Persistent symptoms after viral infection
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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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 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
2 digit month, 2 digit day, 4 digit year
Date
Date of second shot (if applicable)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of third shot (if applicable)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of fourth shot (if applicable)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did you first notice your current symptoms - PLEASE answer this question as accurately as you can.
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any known allergies?
*
Yes
No
Please list any known allergies
*
Please list your regular medications AND supplements. This is very important. You may respond NONE if not on any regular medications.
*
Please list ALL treatments used since the onset of your symptoms including prescription and non-prescription treatments or supplements. You may enter NONE if not on any treatments.
*
Please check any medical conditions or risk factors. Please think carefully and indicate previous and ongoing medical issues. It is important to provide ACCURATE and COMPLETE information so we can advise you 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 provide further details of any illnesses not listed above (date of diagnosis, were you hospitalized or not, treatment, etc.)
In the past 1-2 months have your symptoms?
*
Improved slightly
Improved significantly
Slightly worsened
Significantly worsened
Current date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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 and describe the most problematic symptoms listed above in as much detail as possible.
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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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