Thank you for your interest—Cardiologist

Is Flow Therapy Right for Your COVID-related Symptoms?

The next set of 30 questions will assess your fatigue, shortness of breath, mood, and ability to perform activities of daily living, using standardized tools. Your results will be sent to your email and can help determine whether you could benefit from Flow Therapy.

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Take care of yourself, such as eating, dressing, bathing and using the toilet?
Take care of yourself, such as eating, dressing, bathing and using the toilet?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Walk indoors, such as around your house?
Walk indoors, such as around your house?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Walk a block or two on level ground?
Walk a block or two on level ground?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Climb a flight of stairs or walk uphill?
Climb a flight of stairs or walk uphill?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Run a short distance?
Run a short distance?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do light work around the house like dusting or washing the dishes?
Do light work around the house like dusting or washing the dishes?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do moderate work around the house like vacuuming, sweeping floors, carrying in groceries?
Do moderate work around the house like vacuuming, sweeping floors, carrying in groceries?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do heavy work around the house like scrubbing floors, lifting or moving heavy furniture?
Do heavy work around the house like scrubbing floors, lifting or moving heavy furniture?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do yard work like raking leaves, weeding or pushing a power mower?
Do yard work like raking leaves, weeding or pushing a power mower?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Have sexual relations?
Have sexual relations?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?
Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?*
- Yes
- No

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Participate in strenuous activities like swimming, singles, tennis, football, basketball or skiing?
Participate in strenuous activities like swimming, singles, tennis, football, basketball or skiing?*
- Yes
- No

During the past 7 days…

I feel fatigued…
I feel fatigued*
- Not At All
- A Little Bit
- Some what
- Quite a Bit
- Very Much

During the past 7 days…

I have trouble STARTING things because I am tired…
I have trouble STARTING things because I am tired*
- Not At All
- A Little Bit
- Some what
- Quite a Bit
- Very Much

In the past 7 days…

How run-down do you feel on average?
How run-down do you feel on average?*
- Not At All
- A Little Bit
- Some what
- Quite a Bit
- Very Much

In the past 7 days…

How fatigued were you on average?
How fatigued were you on average?*
- Not At All
- A Little Bit
- Some what
- Quite a Bit
- Very Much

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things
Little interest or pleasure in doing things*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Feeling down, depressed, or hopeless
Feeling down, depressed, or hopeless*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Trouble falling or staying asleep, or sleeping too much
Trouble falling or staying asleep, or sleeping too much*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Feeling tired or having little energy
Feeling tired or having little energy*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Poor appetite or overeating
Poor appetite or overeating*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Feeling bad about yourself—or that you are a failure or have let yourself or family down
Feeling bad about yourself—or that you are a failure or have let yourself or family down*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Trouble concentrating on things, such as reading the newspaper or watching television
Trouble concentrating on things, such as reading the newspaper or watching television*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Moving or speaking slowly that other people have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
Moving or speaking slowly that other people have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Thoughts that you would be better off dead, or of hurting yourself in some way
Thoughts that you would be better off dead, or of hurting yourself in some way*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day

Over the LAST 2 WEEKS, if ANY of the problems previously listed bothered you,

how DIFFICULT have these problems made it for you to do your work, take care of things at home, or get along with other people?
If you checked off ANY problems, how DIFFICULT have these problems made it for you to do your work, take of things at home, or get along with other people?*
- Not Difficult At All
- Somewhat Difficult
- Very Difficult
- Extremely Difficult

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when hurrying on level ground or walking up a slight hill?
Do you get short of breath when hurrying on level ground or walking up a slight hill?*
- Yes
- No

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when walking with other people your own age on level ground?
Do you get short of breath when walking with other people your own age on level ground?*
- Yes
- No

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when walking at your own pace on level ground?
Do you get short of breath when walking at your own pace on level ground?*
- Yes
- No

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when washing or dressing?
Do you get short of breath when washing or dressing?*
- Yes
- No

Please submit the following information for a report to be sent to you by email.

Flow Therapy has demonstrated significant improvement in over 90% of Long COVID patients. It is possible that you may benefit from our treatment program.

If you would like to learn more about Flow Therapy, please contact intake@flowtherapy.com to speak with someone on our team.
Name
First Name*

*Required
Last Name*

*Required
Contact Info
Phone Number
Gender*
Select your gender
How old are you?*
Select your age
Have you had COVID-19?*
When? *
Year*
Month*
Email Address **

*Required
City, State*

*Required
Phone
This field is for validation purposes and should be left unchanged.

Your Information Has Been Submitted

Is Flow Therapy Right for Your COVID-related Symptoms?