Paxlovid Patient Information Form
Please complete this form to see if you are eligible for a Paxlovid prescription.
Date of Birth
Please list any allergies (if none, please write "none"):
Please list all medications you are currently taking, including any over-the-counter medications, vitamins and herbal supplements (if none, please write "none"):
Do you have any of the following medical conditions? (check all that apply; if noe, please click "none of the above")
Immunosuppressive disease (or undergoing immunosuppressive therapy)
Obesity (BMI > 25 in adults)
Neurologic disease (cerebrovascular diseases, Down Syndrome or other neurodevelopmental disorders, or dementia)
Hemoglobin disorder (sickle cell, thalassemia)
Cardiovascular disease (congenital heart disease, heart failure, CAD, Cardiomyopathy, or pulmonary HTN or Hypertension)
Chronic lung disease (COPD/emphysema, moderate-severe asthma, CF, pulmonary fibrosis)
Medical-related technological dependence (tracheostomy, gastrostomy, or positive pressure ventilation not related to COVID-19)
Pregnant or planning to become pregnant
Breastfeeding a child
None of the above
If you have any serious medical conditions not listed above, please list them here:
When did you first start experiencing COVID-19 symptoms?
Which symptoms are you experiencing? (check all that apply)
Fever or chills
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Have you taken a COVID-19 test?
Yes, and my result was positive
Yes, and my result was negative
Yes, and my result was inconclusive or invalid
Yes, and I am waiting to receive my result
No, I have not taken a test
What type of COVID-19 test did you take?
At-home Antigen test (such as BinaxNow, Flowflex, QuickVue or iHealth)
At-home Molecular test (such as Cue, Detect or Lucira)
Antigen test administered by a healthcare professional
Rapid Molecular test administered by a healthcare professional
Lab PCR test administered by a healthcare professional
If you tested outside of modMD, please upload your COVID-19 test result here. If you tested with modMD, you do not need to upload your result.
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