Intake questionnaire


Thank you for filling out the intake questionnaire. Your responses will be kept strictly confidential. Please skip any questions that you do not know the answer to. For added security, make sure to close your web browser after you submit this form.

Fields with * are required.

1. Assigned unique identifier. DO NOT use your name.*

2. Year of birth*

3. Today's date*

4. Are you feeling sick today?* Please choose from the pulldown menu.

5. Are you experiencing any of the following symptoms? Please check all that apply.
CoughSore throatFeverDifficulty breathingNew vomiting or nauseaNew diarrheaChange in smell or tasteNew unexplained fatigue
6. Have you had close contact with a confirmed or probable cause of Covid-19 recently?*

7. Are you left or right handed?
LeftRight
8. Please list your current medications, separated by commas

9. Please list any existing health conditions (eg. diabetes, high blood pressure...), separated by commas

10. Please list any previous surgeries, separated by commas

11. Please list any allergies

12. Please list all health conditions that run in your family

13. What is your occupation?

14. Do you smoke? If yes, how many cigarettes per day?

15. Do you drink alcohol? If yes, how many drinks per week?

16. Do you use street drugs? If yes, please list.

17. Do you have any of the following medical conditions? Please mark all that apply.
HIVHepatitis CPacemakerBleeding disorder
18. Are you taking blood thinner medications?
YesNo
19. What is the main problem that we can help you with?

20. When did the symptoms start?

21. Was there an injury before? If yes, please describe.

22. Are you experiencing any of the following? Please mark all that apply.
Numbness/TinglingWeaknessPainWeight lossChanges in balanceNight sweats
23. If you checked off any boxes in question 22., please explain.

24. Are your symptoms constant or intermittent? If intermittent, how often do you experience them?

25. What activities make your symptoms better?

26. What activities make your symptoms worse?

27. Are you experiencing any bowel or bladder changes related to your current problem? If yes, please explain