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Post-COVID Clinic Pre-Screening Form
Please fill out the form below and one of our program coordinators will contact you regarding the next steps. If you have any questions, you can contact us directly at 646-513-3314. Thank you!
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Please enter a phone number where we can best reach you at.
*
Please verify that your phone number is correct so we are able to contact you.
Your answer
Please enter an email address where we can best reach you at in case we're not able to contact you via phone.
*
Your answer
Have you tested positive for COVID?
*
Yes
No
Were you hospitalized?
*
Yes
No
Initial date of onset of disease?
*
Around when were you infected?
MM
/
DD
/
YYYY
How many days has it been post-infection?
*
Your answer
Which symptoms did you experience while you were infected?
*
Fever
Dry cough
Difficulty breathing
Chest pain
Fatigue
Irregular heartbeat
Palpitations
Other:
Required
How long did you experience these symptoms for?
*
Your answer
On a scale of 1 - 10, how severe were the symptoms that you experienced while infected?
*
Not severe
1
2
3
4
5
6
7
8
9
10
Very severe
Which of the following symptoms (if any) are you still experiencing?
*
Difficulty breathing
Chest pain
Palpitations
Faint / loss of consciousness
Fatigue
Shortness of breath
Irregular heartbeat
Other:
Required
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