Language for telemedicine consult (other than English)

Full Name *

Date of birth *

Email *

Phone *

Address *

State / Country

Postal code *

How did you hear about us?

Details: (list doctor's name/social media channel / website name / who referred you)

Have you been vaccinated against covid-19? List dates and manufacturer if known (M=Moderna, P = Pfizer, J = Johnson & Johnson

Have you been infected with covid-19 virus: list dates;

Do you have PoTS ?

Yes

Do you have chronic fatigue (ME/CFS) ?

Yes

Do you have MCAS ?

Yes

Risk factors (select as many as you have):

Select all the symptoms that you have:

Systemic

Neurological:

Psychiatric:

Pulmonary:

Cardiovascular (heart/blood vessels):

Dermatologic:

Gastrointestinal:

Musculoskeletal:

Reproductive:

Immunologic:

Other symptoms not listed:

Blood work (select all you had):

Of the bloodwork you have had done, were any of the results abnormal?

Over the counter supplements (select all that you take):

Prescription medications: (select any that you tried):

Other medications and supplements:

Do you use a Vagus Nerve Stimulator?

Have you tried the nicotine patch?

Have you had an SGB (stellate ganglion block)? Was it level 1 or 2? (one shot or 2 on the same side) Was it done with ultrasound? Did you have horners syndrome? (red eye, small pupil, droopy eye, stuffy nostril)

What other treatments have you tried?