Viral Defense Questionnaire

Viral Defense Questionnaire

Luminnova Health
Name*

First NameMiddle InitialLast Name
Birth Date*

DayMonthYear
Date
Gender*

FemaleMale
Email*
example@example.com
Purpose for using the Luminnova Health PDT kit

Sporadic Viral Defense Measures (e.g. air travel)Acute viral illness including CoVID-19Extended viral prophylaxis (contingency)
Phone Number*
Please enter a valid phone number.
Second Phone Number (relative)
Please enter a valid phone number.
Street Address
Please provide directions to your house

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.
Should be Empty:

	Absent	Very Mild	Mild	Moderate	Severe
Loss of taste or smell
Difficulty breathing
Runny nose/nasal congestion
Cough
Headache
Chills
Abdominal Pain
Diarrhea
High fever
Sore throat
Body aches
Persistent pain or pressure on chest
Fatigue
Nausea/vomiting

Health and Medical History