RTHM Waitlist
RTHM expects to start seeing patients in early 2022. Please complete the intake survey below to be added to the waitlist. We will contact you with more information.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Country
*
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Date of birth
*
-
Month
-
Day
Year
Date
I am interested in:
Becoming a patient of RTHM telehealth services
RTHM research studies
Research studies conducted by RTHM collaborators
Type option 4
When do you suspect you first contracted COVID?
*
-
Month
-
Day
Year
Date
For how long have you experienced Long COVID symptoms?
*
1 - 2 months
2 - 6 months
6 - 12 months
More than 12 months
Was your COVID confirmed by a test?
PCR test
Rapid antigen test
Antibody test
T-cell test
Imaging (X-ray, CT)
Clinician confirmed though no test performed
None of the above
Was your COVID confirmed by any of the tests below? (select all that apply)
PCR test
Rapid antigen test
Antibody test
T-cell test
Imaging (X-ray, CT)
Other
Were you hospitalized with COVID?
Yes
No
Did you require any of the following as part of your COVID care? (check all that apply):
Supplemental oxygen
ICU level care
Non-invasive ventilation (BIPAP, etc.)
Intubation (breathing tube)
Treatment with dexamethasone
Treatment with Remdesivir
Treatment with monoclonal antibodies
Did you experience any of the following issues in association with COVID? (check all that apply):
Blood clots (DVT, pulmonary embolism, etc.)
Heart attack, heart failure, myocarditis, or pericarditis
Renal failure (requiring dialysis)
Acute respiratory distress syndrome (ARDS)
Guillain-Barré syndrome, Miller Fisher syndrome, transverse myelitis
Seizures, coma, stroke, and/or psychosis
Other
Do you have a primary care doctor you've seen in the past six months?
*
Yes
No
Are you already established with any of the following specialists (check all that apply):
Neurologist
Rheumatologist
Gastroenterologist
Cardiologist
Pulmonologist
Hematologist
Pain management & rehabilitation (PM&R) or physiatrist
Psychiatrist
Mental health therapist
Physical therapist
Home health
Other
Do you have health insurance?
*
Yes
No
What type of health insurance do/will you have?
Employer-sponsored plan
Non-employer plan (individual plan)
Kaiser Permanente
Medicare Standard
Medicare Advantage
State insurance
VA or TRICARE
Other
Are you comfortable having medical conversations in English without a translator?
Yes
No
Are you comfortable having medical conversations in English without a translator?
Yes
No
Which description below best characterizes your current quality of life?
I am able to carry on normal activity; minor signs or symptoms of disease.
I can do normal activities with effort; some signs or symptoms of disease.
I can care for myself, but I am unable to carry on normal activity or to do active work.
I require occasional assistance, but I am able to care for most of my needs.
I require considerable assistance and frequent medical care.
I am disabled and require special care and assistance.
I am severely disabled; hospitalization is indicated
How much are you currently affected in your everyday life by Long COVID?
*
I have no limitations in my everyday life and no symptoms, pain, depression or anxiety.
I have negligible limitations in my everyday life as I can perform all usual duties/activities, although I still have persistent symptoms, pain, depression or anxiety.
I suffer from limitations in my everyday life as I occasionally need to avoid or reduce usual duties/activities or need to spread these over time due to symptoms, pain, depression or anxiety. I am, however, able to perform all activities without any assistance.
I suffer from limitations in my everyday life as I am not able to perform all usual duties/activities due to symptoms, pain, depression or anxiety. I am, however, able to take care of myself without any assistance.
I suffer from severe limitations in my everyday life: I am not able to take care of myself and therefore I am dependent on nursing care and/or assistance from another person due to symptoms, pain, depression or anxiety.
How did you become aware of RTHM Clinic?
*
Facebook post
Instagram post
LinkedIn post
Reddit post
Google search
Media article/video
Friend
Other
Any other details about your case that you wish to provide:
Submit
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