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Thursday

January 27, 2022

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Step 1 Title

Step 1

Personal Details

Set Password
  •   Your password must contain at least one lower letter.
  •   Your password must contain at least one uppercase letter.
  •   Your password must contain at least one Number (0-9).
  •   Your password must contain at least one Special Character.
  •   Space is not allowed.
  •   Your password must be between 6 and 30 characters.
  •   Passwords do not match.
Patient Ethnicity
I consider myself: *
Patient Race
Which of the following racial designations best describes you (select one or more): *

Step 2 Title

Health Insurance Details

Do You Have Insurance?

Health Insurance Details

Out of Network Coverage?
Active Now?
Insurance Start Date
Deductibles Met?
Co-Insurance (Supplemental Plan B, or Other)?

Upload Government Issued ID
Upload Insurance Front Side
Upload Driving License Back Side
If you Don't have Insurance, Fill this REQUISITION Form

Upload Insurance Back Side

Step 3 Title

Insurance / Payment Details

Do you have insurance? *
How will you be paying? *

Step 4 Title

PRE-EXISTING CONDITIONS

I have following condition(s): *
I have a condition that weakens my immune system or makes it harder to fight infections: *
I am taking one of these medications: *
Yes, I live, work or have visited a place where COVID-19 is widespread. *
Have you possibly been exposed to the Coronavirus in the past 2 weeks? *
Yes, I have been in close proximity (within 6 ft.) to someone who has been diagnosed with or presumed to have COVID-19. *
Do you have Diabetes Mellitus?
Are you suffering from Cardiovascular disease?
Are you suffering from Chronic Renal disease?
Are you suffering from Chronic Liver disease?
If female,are you currently pregnant?
Do have Immuno disorder?
Are you suffering from Neurological disability?
Are you suffering from Intellectual disability?
>
Do you have Other chronic diseases?
Do you have any Chronic Lung disease(asthma/emphysema/COPD)?
Yes
Other,specify

EXPOSURE

Travel to a non-US country with a lab-confirmed SARS-CoV-2 (COVID-19) patient?
In the last 14 days, have you come into contact with a person(s) known to be infected with COVID-19? *
If yes, was this person a U.S. case?

Step 6 Title

Have you had any of the following symptoms since December 2019: *
Are you currently experiencing any of these symptoms? *
ABSENT (No symptoms) - 0
Mild (Present, but minimal) - 1
MODERATE(tolerable) - 2
Severe - 3

Symptoms

Nasal discharge(runny nose)

0

1

2

3

Nasal obstruction (stuffy nose)
Nasal itching
Itchy ears
Itchy eyes
Itchy throat
Watery eyes
Gritty feeling(eyes)
Sensitivity to pet hair
Hives
Eczema
Sneezing
Sinus pressure
Sinus_pain
Sinus or ear infections
Wheezing
Difficulty breathing
Shortness of breath(Dyspnea)
Frequent colds or sore throat
Cough
Headache
Fever/Chills
Muscle aches(myalgia)
Diarrhea
Abdominal pain
Nausea or vomiting
Loss of smell or taste
Feeling tired,fatigue
Red/Purple bumps on hands or toes/feet
Pinkish Eyes
Expectoration (Phalegm or Mucous)

Step 7 Title

ASTHMA/ALLERGY HISTORY

Do You Have Allergies?
Do you smoke or use tobacco products?
I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
List any animals you are around on a regular basis.
Did the patient have another diagnosis/etiology for their illness?
If yes, what diagnosis?
Does the patient have an abnormal chest X-ray?
Does the patient have acute respiratory distress syndrome?

ASTHMA/ALLERGY MEDICATIONS

Antihistamines

0

1

2

3

Eye drops
Ointments
Nasal steroids(Flonase, Nasacort)
Oral steroids
Asthma medication(Inhaler, Singulair, Advair)
Other allergy medications?

Step 6 Title

Consent Form

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