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Telemedicine Consultation Form

Post-COVID Syndrome

Please complete the following Clinical form if you wish to be treated for Post-COVID Syndrome

Throne Clinical History Form For Post-COVID Syndrome

This is a form to submit information for the treatment of Post-COVID Syndrome (also known as Long COVID Syndrome) patients for possible treatment with Throne Biotechnologies’ Stem Cell Educator Therapy. Post-COVID Syndrome applies to those who had a COVID infection or a COVID vaccine and who were never fully recovered from after three months. The typical symptoms are (1) feeling fatigued most of the time, especially after physical activity and (2) "brain fog," a feeling of inability to think clearly. In addition to these symptoms, there may be other chronic symptoms involving other parts of the body. The syndrome is probably caused by the persistence of the inflammatory COVID spike protein in various organs of the body, whether the spike protein came from a COVID infection or a COVID vaccine. The persistent spike protein then often causes autoimmune inflammation in various organs, including the heart, lungs, brain, and the blood vessels of those organs. Stem Cell Educator Therapy often decreases or eliminates this autoimmune inflammation permanently unless there is further exposure to spike protein.

If you wish to be considered for treatment of Post-COVID Syndrome with Throne’s Stem Cell Educator Therapy, please submit the following information

Your Name
Your Name
First Name
Last Name
Your Address
Your Address
City
State/Province
Zip/Postal
Country
Your Sex

COVID-19 Infection History

How many times do you think that you have had a COVID-19 infection, regardless of any test results?
How many COVID-like illnesses have you had during which you tested positive for COVID-19 infection?
If you had a COVID infection, how fully have you recovered from that most recent COVID infection? Enter "None" if no COVID infection.
If you had a COVID infection, when were you first treated for your most recent COVID-19 infection? Enter "None" if no COVID infection.
If you had a COVID infection, were you hospitalized for your COVID-19 infection?
If you had a COVID infection, were you hospitalized in intensive care for your COVID-19 infection?
If you had a COVID infection, did you require a mechanical ventilator to breathe when you hospitalized in intensive care for your COVID-19 infection?
If you had a COVID infection, did you receive any prescription medications for the treatment of your COVID-19 infection at the time of it? Check all that apply.
If you had a COVID infection, did you receive any non-prescription medications for the treatment of your COVID-19 infection at the time of it? Check all that apply.
If you had a COVID infection, how long after you started treatment was it until you began to feel better?

COVID Vaccination History

How many COVID vaccinations have you had?
Which initial series did you have?
How long after your COVID vaccination did you first develop signs of an adverse reaction, such as fatigue at rest, excessive fatigue after exertion, "brain fog"?
How serious was your adverse vaccination reaction?
When did you first seek medical attention for your COVID vaccine adverse reaction?

Post-COVID Severity Score

Sensory deficits
None
Mild
Moderate
Severe
Life-threatening
Smelling disturbances
Impaired sense of taste
Fatigue that interferes with daily life Symptoms that get worse after physical or mental effort.
None
Mild
Moderate
Severe
Life-threatening
Tinnitus
Joint or muscle pain
None
Mild
Moderate
Severe
Life-threatening
Muscle pain
Joint pain
Ear-Nose-Throat (ENT) ailments
None
Mild
Moderate
Severe
Life-threatening
Hoarseness
Sore throat
Running nose
Coughing, wheezing
None
Mild
Moderate
Severe
Life-threatening
Coughing
Wheezing
Chest pain
None
Mild
Moderate
Severe
Life-threatening
Chest pain
Gastrointestinal ailments
None
Mild
Moderate
Severe
Life-threatening
Stomach pain
Diarrhea
Vomiting
Nausea
Neurological ailments
None
Mild
Moderate
Severe
Life-threatening
Confusion
Vertigo (dizziness)
Headache
Motor deficits (weakness)
Sensory deficits
Numbness
Tremor
Inability to concentrate
Skin issues
None
Mild
Moderate
Severe
Life-threatening
Hair loss
Rash
Itching
Signs of infection
None
Mild
Moderate
Severe
Life-threatening
Chills
Fever
General illness, flu-like symptoms
Sleep disturbance
None
Mild
Moderate
Severe
Life-threatening
Insomnia
Unrestful sleep
General Symptoms (check all that apply)
Psychological symptoms (check all that apply)
Decreased mobility due to pain or arthritis of hands, back, hips, or knees
Heart symptoms (check all that apply)
Respiratory symptoms
Blood clotting disorders
Digestive symptoms (click all that apply)
Reproductive symptoms (check all that apply)
New or recurrent cancer

General Health

Do You Have Any Of These Other Autoimmune Disorders? Check All That Apply:

Social History

Do you have a spouse or significant other relationship at this time?
Are You Employed At This Time?
Do You Have Or Need A Caretaker And, If So, Who Supplies That Care?
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