Viral Defense Questionnaire

  • Viral Defense Questionnaire

    Luminnova Health
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  • Gender*
  • Purpose for using the Luminnova Health PDT kit
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Health and Medical History

  • 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.*
  • Do you have any known allergies?*
  • Have you had recent contact with a known CoVID-19 positive patient? Check any that apply
  • Have you had a CoVID-19 test within the past 2 weeks?*
  • CoVID-19 test result*
  • Have you had a CoVID-19 vaccine?
  • Which vaccine have you received:
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  •  - -
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  • Have you been previously diagnosed with COVID-19?*
  • How many respiratory infections have you had within the past 12 months?
  • Have you had ANY recent symptoms that may suggest CoVID-19 or other infectious illness? Please answer yes even if you think the symptoms may be due to another cause, e.g. sinusitis
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  • Are your symptoms*
  • Rows
  • Do you currently have diarrhea?
  • How many bouts of diarrhea per day?
  • Do you have a pulse oximeter at home? (Note: this is advisable for all households).*
  • Do you have a reliable thermometer at home? (Note: this is advisable for all households).*

  • Household

  • Please note that ALL members of your household should be treated t the same time if there you have had a high risk exposure or if you have CoVID-19 infection.

  • Do any members of your household have any of the CoVID-19 symptoms above?*
  • Should be Empty: