New Acute COVID Infection Patient History New Acute COVID Infection History New Acute COVID Infection Patient History Demographics Patient First Name * Patient Last Name * Patient Street Address * Patient City * Patient State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Patient Zip Code * Patient Birthdate * Patient Age Patient Phone * Patient Email * Patient Sex * Female Male COVID History Are you having any of the following? * fever between 100 and 102 degrees fever above 102 degrees cough difficulty breathing chills sore throat ear ache runny nose headache muscle ache very tired, fatigued loss of ability to taste or smell none of the above If you are having any of the above symptoms, for how many days have you been having them? * One day Two days Three days Four days Five or more days I am not having any of these symptoms If you have had a COVID-19 test, what was the result? * no test to date negative positive result not back yet If you have had a COVID-19 test, what was the date you had the test? (enter "none" if none) * How Many COVID Vaccine Shots (Including Boosters) Have You Had? * None One Two Three Four Five or more How many previous COVID-like illnesses have you had during which you tested positive for COVID-19 infection? * None One Two Three Four Five or more How many months ago did you have your most recent COVID-19 infection? General Health Please list all of your chronic medical problems: Please list all the times you have had to stay in a hospital overnight, the main reason you were there, and how long you were there: Please list all the surgical procedures or operations for which you have to be sedated or put to sleep, the dates of those surgeries, and any complications: Please list all the prescription drugs that you are taking at this time and the reasons that you take them: Please list all the drugs and foods to which you are allergic: If you are having any fever, enter your highest temperature in the past 24 hours, if no fever, enter "none" * Your pulse/heart rate (for example: 70) * Your breathing rate per minute (for example: 18) * Your pulse oximeter oxygen % reading (if you don't have a pulse oximeter, enter"none") (seek emergent medical attention if below 90%) * Your weight (in pounds) Your height ( in feet and inches)(for example, 5' 6") List any other current illnesses (enter "none" if none) Do you have any of these chronic conditions? diabetes chronic lung disease chronic heart disease heart failure heart rhythm disorder/pacemaker cancer none of the above List any other chronic conditions (enter "none" if none) Are you a member of any of these COVID high risk groups? Black or African-American Hispanic or Latino Police, Fire, EMS Police, Fire, EMS Hospital Worker None of the above The chain pharmacies are refusing to fill ivermectin prescriptions. The followingpharmacies have such prescriptions. Select one or make your own suggestion if you know they take such prescriptions: Savco Pharmacy, 455 O'Connor Drive, Ste. 190,, San Jose, CA, 408-298-6190 (mail delivery available) Lauden Pharmacy, 1820 41st Ave., #F, Capitola, CA, 831-462-9880 Suggest another pharmacy in "Comments" below Do You Have Any Other Comments Or Questions Or Is There Anything Else That You Wish To Mention? TeleHealth & Follow-Up Authorization: I give permission to this office to treat me bymeans of telehealth services pursuant to Governor Newsom's Order of April 3, 2020,to communicate with me through the email address provided above * Yes Required Medical Board of California Notice To Consumers: Richard B. Fox, M.D.,J.D., CA Medical License #G67169 provides this NOTICE TO CONSUMERS: Medicaldoctors are licensed and regulated by the Medical Board of California (800) 633-2322www.mbc.ca.gov. Click "yes" to acknowledge receipt of this legally required notice. * Yes Services Provided & Payment Requested: Upon submission of the above information, Dr. Fox will review it and send you a recommendation for treatment of your COVID-19 infection. If you wish to have this telemedicine service provided, please send $100 by the Zelle payment transfer service to phone number 408-402-2452. Upon receipt of your payment your prescriptions will be sent to your requested pharmacy and copies of those prescriptions will be sent to you at your listed email address. Do you wish to proceed under the above agreement? Yes No Submitted By: Submission Date File Name If you are human, leave this field blank. Submit
