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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

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 Gender

General Health

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

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

General Symptoms (check all that apply)
Heart symptoms (check all that apply)
Respiratory symptoms
Digestive symptoms (click all that apply)
Decreased mobility due to pain or arthritis of hands, back, hips, or knees
Blood clotting disorders
Reproductive symptoms (check all that apply)
Psychological symptoms (check all that apply)

General Symptoms

General illness, flu-like symptoms
Fatigue that interferes with daily life, symptoms that get worse after physical or mental effort.
Insomnia
Fever
Chills
New or recurrent cancer

Ear, Nose, Throat Symptoms

Ringing in the ears
Running nose
Sore throat
Hoarseness
Smelling disturbances
Impaired sense of taste

Chest Symptoms

Coughing
Chest pain
Wheezing

Digestive Symptoms

Stomach pain
Vomiting
Nausea
Diarrhea

Neurological Symptoms

Inability to concentrate
Confusion
Headache
Sensory deficits, numbness, tingling, etc.
Motor deficits (weakness)
Vertigo (dizziness)
Tremor

Musculo-skeletal Symptoms

Joint pain
Muscle pain

Skin Symptoms

Rash
Itching
Hair loss

Social History

Are You Employed At This Time?
Do You Have Or Need A Caretaker And, If So, Who Supplies That Care?
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