Post-Viral Infection Questions
Includes Covid (any variant), EBV, CMV, flu, etc.
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Email *
First and Last Name *
Date of Birth *
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Today's Date *
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Answer all of the following symptoms/questions, even if they are only slightlybothersome, rarely occurring (for instance, not necessarily present currently butin the past), or may seem not be related to your main problems. *
Yes
No
Do you get colds regularly which then turn into bacterial infections such as sinus infections or bronchitis?
Has the course of your illness been episodic (and/or with attacks)
Have the symptom free times become shorter as you aged?
Date of Covid infections (to the best of your knowledge). Include DATE, VARIANT *
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Have you been diagnosed with any other viral issues: *
Describe any treatment you received during your infection. *
If the statement applies to you, check the box and then enter the intensity level on theline next to the box. The number should be graded when it was present the last time itoccurred. If the statement does not apply, Check n/a *
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N/A
Significant physical weakness or fatigue doing everyday activities
Extreme fatigue attacks, hard to keep eyes open
I lose weight despite maintaining my normal diet
Ears have rining or odd sounds
Eyes are dry, itchy, red, burning, gritty
Runny or stuffy nose
Inflammation or ulcers of mouth
Burning or pressure in chest
Rapid heart rate (palpitations)
REdness or fliushing of skin, espeically face or upper body
Hot flashes (not related to hormones)
Sudden dizziness/lightheadedness with fainting or near faint
Irritable dry cough or need to cough
Feeling short of breath, difficulty taking in a full breath
Asthma like complaints
Attacks of visible bloating or distension
Pain in abdomen
Pain is burning
Pain is cramping or spastic
Pain is associated with diarrhea
Nausea (with or without vomiting)
Bladder or pelvic pain
Pain during sex
Increased pain or bleeding during menses
Migraine like headaches
Brain fog or memory difficulties
Leg or arm pain: numbness, tingling, burning, sharp pain, pins and needles
Hives or rashes
Hemiangiomas (raised or flat bright red spots
Itching acne on face
Knots or nodules under skin
Painles non-itchy swelling (esp of face)
Itching in area around anus during attacks
Increase in bruising
unusual nose bleeds
Bone pain
New osteopenia or osteoporosis after infection
Chills
Consitpation
Do high histamine foods worsen symptoms (wine, cheese, chocolate, yogurt, deli meat, tomatoes, alcohol) *
Do antihistamines help reduce nausea (ex: benadryl, Claritin) *
*
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N/a
Loss of smell
Loss of tastes
Dry Mouth
Dry Eyes
Sweats
Hair Loss
Sleep *
Yes
No
Do you have a sleep apnea device
Do you snore loudly
Do you often feel tired, fatigued, or sleepy during the day
Has anyone observed you stop breathing during your sleep
Do you have or are you being treated for high blood pressure
Is your neck sizer larger than 16 inches
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